Other key organisations / parties

Medical practitioners

The role of medical practitioners in the coroner’s court

When a person dies, a medical practitioner who was responsible for a person's medical care immediately before death, or who examined the body of a deceased person after death, must decide whether they will write out a Medical Certificate of Cause of Death (MCCD) or whether they will report the death to the coroner. They are required to carefully consider the provisions of section 3 of the Act and decide if the death is reportable. If the doctor decides that the death is not reportable, then they must issue a MCCD stating the cause of death and any conditions that were precursors to, or contributed to, the death. If the doctor decides that the death is reportable, then they will report it to the coroners’ associates (or a police officer) and the coronial investigation begins.

Many different medical practitioners assist the coroner’s court. Most often, their role is to provide information about the deceased person’s medical history and the circumstances of their death. These medical practitioners may have been providing care to the deceased at their time of death (such as staff at hospitals and residential aged care facilities) or they may have been treating the deceased person before they died (such as a general practitioner (GP), dentist or physiotherapist).

Sometimes a deceased person may have experienced a specific health complaint that required the assistance of mental health services, drug and alcohol services or disability support services. In cases such as this, the coroner will usually request access to the records of these services, and assistance from treating doctors to understand the nature and progression of the deceased person’s illness or disability.

The coroner may ask a doctor to provide a statement for the coronial file, or to prepare an expert report on the treatment they have provided, or on the patient’s medical condition/s. If families or friends wish to read the post mortem report of a loved one (which is prepared by a qualified pathologist), a doctor may be asked to receive the report and help the families and friends to understand the medical language used.

If a doctor is involved in a coronial proceeding, they may be requested by the coroner’s court to do any of the following:

  • review a decision not to issue an MCCD in relation to a death
  • provide the complete medical records of the deceased
  • provide information on:
    • family history
    • the circumstances of death
    • the progression and treatment of any medical conditions suffered by the deceased
    • any medical conditions which may have contributed to, or been a precursor to, the death
  • provide a statement or report to the coroner
  • assist families and friends to understand medical reports and documents (including the post mortem report)
  • provide an expert report
  • give evidence in court about the death and any event/s which preceded it
  • give expert evidence.

The focus of a coronial investigation is to find out what caused and contributed to the death, and in some investigations, to prevent it from happening again. The focus in medical related matters is often on systemic issues. By focussing on the system in which mistakes occurred, a coroner can make recommendations to improve the system and prevent future deaths.

If you are a medical practitioner and you are seeking advice on whether a particular death is reportable, please refer to the information provided in When to report a death to the coroner.

When to report a death to the coroner

This is a guide prepared for medical practitioners to assist them to determine whether a death is reportable. It is included in the Handbook as the information may be useful to legal practitioners if they are required to advise clients on this and related issues.

When a death occurs, a medical practitioner who was responsible for a person's medical care immediately before death, or who examines the body of a deceased person after death has an important decision to make:

Do I write out a Medical Certificate of Cause of Death (MCCD) or report this death to the coroner?

  • If you can issue a MCCD but don’t within 48 hours, you are guilty of an offence
  • If you have to report a death to the coroner and you don’t as soon as possible, you are guilty of an offence
  • Both these offences carry a penalty not exceeding 10 penalty units ($1,570 in 2016-2017).

So how do you make the right decision?

  • Take a reasonable time to review the deceased person’s medical records.
  • Ask the police, or other relevant parties, about the circumstances of death.

You do not need to have treated the deceased within a certain period before death, (or ever) to complete a MCCD or report a death.

You do not need to report a death if someone else has already done so.

Is this death reportable?

The Coroners Act 1995 (Tas) contains an exhaustive definition of ‘reportable death’. The most relevant sections of the definition for medical practitioners are:

A death:

  • iv. that appears to have been unexpected, unnatural or violent or to have resulted directly or indirectly from an accident or injury; or
  • v. that occurs during a medical procedure, or after a medical procedure where the death may be causally related to that procedure, and a medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death; or
  • vii. the cause of which is unknown; or
  • ix. of a person who immediately before death was a person held in care or a person held in custody; …

Whether a death was “natural” in a medical or a legal sense is often very difficult to ascertain. There are often natural and unnatural causes contributing to a death, which may be present in various degrees. With this in mind, below is a practical checklist to assist medical practitioners to determine whether they are required to report a death to the coroner.

If you answer “yes” to any of the following questions, the death is reportable.

  • Does it appear that an injury or an accident contributed to the death?
    • The injury / accident does not need to be recent; there is no time limit.
    • It includes any injury / accident that contributed to the death in any way that was not minimal or trivial.
    • Example one: If a motor vehicle crash causes paraplegia and the person dies years later from a complication of the paraplegia, this death is reportable.
    • Example two: If an elderly person suffers a fall which results in a fractured neck of femur and this accident hastens death, even if natural processes contributed to the fall, it is likely the death is reportable.
  • Was the death possibly a suicide (or unintentionally self-inflicted)?
    • this includes situations where you have concerns that a person may have contributed to their own death by overdose or neglect.
  • Does it appear that violence contributed to the death?
    • Are there suspicious circumstances, or a history of violence, which suggests violence may have contributed to the death?
  • Was the person in police or government care or custody?
    • this includes someone who is being taken into custody or trying to escape from custody
    • this includes a prison, a detention centre or a secure mental health unit
    • this includes a person under a Mental Health Order
    • this includes a child under a Child Protection Order, who is under the custody or guardianship of the Secretary.
  • Was the person a child under one year of age, and the death sudden and unexpected?
    • an infant who is born deceased (a stillborn) is not reportable
    • a neonate who shows signs of life outside the womb and then dies will be reportable if the death was also sudden and unexpected.
  • Is the cause of death unknown?
  • Is the identity of the deceased person unknown?
  • Did the death occur during a medical procedure?
    • A ‘medical procedure’ is any procedure performed on a person by, or under general supervision of, a medical practitioner (including imaging and external examination).
    • A death which occurs during a medical procedure is reportable if the death would not have been reasonably expected by a medical practitioner immediately before the procedure was undertaken.
  • Is it reasonably possible that the death is related to a medical procedure, treatment or lack of treatment?
    • A death which occurs after a medical procedure is reportable, if:
      • the person would probably not have died at the same time if the treatment had not been provided, and
      • the death would not have been reasonably expected by a medical practitioner immediately before the procedure was undertaken.
    • A death may be related to lack of treatment, if:
      • the death would probably not have occurred at the same time if the treatment had been provided, and
      • a medical practitioner in the same situation would reasonably have expected that the treatment would be provided.

NOTE for medical setting deaths:

In deciding what it was reasonable to expect, take account of:

  • the state of the deceased’s health at the time medical treatment was sought
  • the clinically accepted range of risk associated with the treatment
  • the circumstances in which the treatment was sought.

If you answered “no to all these questions and you are confident you are able to attest to the cause of death then you must complete a MCCD.

If you have any doubt about whether a death is reportable, you should seek advice from a coroners’ associate immediately. They are available at the coroner’s court during business hours and on-call outside office hours through the police radio room (131 444). The deceased person should be left in place pending advice (as advice can be provided immediately).

Completing a MCCD

If you require guidance on how to fill out a MCCD, please see Information Paper: Cause of Death Certification ABS 2008, 1205.0.55.001 and the accompanying Quick Reference Guide.

Reporting a death to the coroner

How are deaths reported to the coroner?

  • All deaths should be reported immediately to a coroners’ associate over the phone (see contact details below). You can also report the death to a police officer if a coroners’ associate is not available or a police officer is already present.
  • The Coroners Rules say that deaths must be reported in writing, or the report confirmed in writing, within 48 hours. The coroners’ associates / police will complete the written report for you.
  • If you are a doctor in a hospital, that hospital may have its own form to report deaths to the coroner. Seek advice from your supervisor to ascertain if you have to complete a form.

Is there a requirement to provide a requested document or statement to the coroner?

  • You are advised to comply immediately with any request for documents as the coroner has the power to authorise a police officer to enter any place, seize the documents and take a copy. This includes medical records and imaging.
  • The coroner is not required to pay for copies of documents (once they are requested, they become evidence in a coronial investigation).
  • Any requests should be treated as urgent.
  • Confidentiality laws do not apply to documents requested by the coroner. Any records or documents provided will only be used for the purpose of the investigation.
  • The coroner may request that you provide a statement to aid the investigation. You are not required by law to provide a written statement. However, any person who reports a death must give the coroner any information which may help the investigation (failure to do so is an offence).
  • The coroner may send a summons requiring you to attend court and give evidence. Failure to comply with a summons is an offence.

Preparing the deceased person for the coroner:

  • Always leave any clinical support equipment / medical apparatus in place.
  • If there are any needles or other “sharps” present in the body at death and these are left in place, you must notify the coroners’ associate upon reporting the death.
  • Do everything possible to ensure that the deceased person remains in the same condition as they were at the time of death.

Religious and cultural concerns

Certain religions have beliefs regarding burial / cremation that require the body to be released very quickly. Others may object to post mortem procedures such as autopsy or the taking of blood. If you are aware of any such concerns, you should notify the coroner upon reporting the death.

Religious, cultural and other support groups

Religious, cultural and other support groups play a vital role in assisting the families and friends of deceased persons to negotiate the coroner’s court. People from religious and cultural minorities can sometimes feel uncomfortable expressing their views to public officials. Past experiences, both personal and historical, can cause fear and anxiety and prevent people freely communicating their feelings. Support groups include any group that provides individual or social support to a particular group in society based on ethnic background, sexuality, gender identity, disability or any other attribute.

A religious, cultural or other support group whose members understand the needs and beliefs of affected families and friends can help bridge the gap between the coroner’s court and those individuals. Anyone can contact such a group and they can talk to the court on that person’s behalf, explaining their views. If your client is a member of a particular social group with diverse needs, then the use of a support group as an intermediary may assist them to express their views and concerns in a clear manner.

Religious, cultural and other support groups can also help coroners to understand how a deceased person may have felt about certain issues or in certain situations, giving them a deeper understanding of the deceased person and their life. Understanding the viewpoints of the families and friends of the deceased person can also help the coroner and the coroners’ office to communicate in an appropriate, respectful manner when dealing with the bereaved.

For information on groups that may be able to assist, refer to A Guide for Families and Friends: Who can help?.

The National Coronial Information System (NCIS)

The National Coronial Information System (NCIS) is the national data repository for coronial information. The NCIS holds information about deaths reported to a Coroner in Australia and New Zealand. The function of the NCIS is to develop and maintain a high quality information service for coroners, policy makers and researchers to benefit the community by contributing to a reduction in preventable death and injury.

The NCIS provides national case information to assist in coronial investigations, as well as statistical data to agencies including the Australian Bureau of Statistics and the Commonwealth Department of Health. The data is used to inform community health and safety strategies. Data reports may be provided, subject to coronial approval, and access to the database may be available for ethically approved research. To find out more, visit www.ncis.org.au

Registry of Births, Deaths and Marriages

The Registry of Births, Deaths and Marriages (BDM) maintains the Register of all deaths in Tasmania. It also issues Death Certificates and provides statistical data to government departments and some approved private organisations. Once the coroner’s court receives the initial police Report of Death, a Registration of Death Statement is generated and sent to BDM. The death is then registered and an interim death certificate can be issued.  The certificate will have an endorsement stating ‘incomplete registration – cause of death subject to coronial inquiry’. Once the cause of death has been determined, the coroner’s court notifies BDM.  BDM then finalise the death registration and the endorsement is removed. After this, anyone who received an interim death certificate can return it to BDM in exchange for a standard Death Certificate.  If you require a copy of a Death Certificate, you may apply to Service Tasmania.

For more information on Death Certificates, refer to Key Elements in the Process: Documents.

The coroner is required to state the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999 in their findings if possible (s 28(1)(e)). At this point, there is no legislation stating which particulars are required to register a death. The practice of coroners is to only record the personal particulars which may be appropriate in the circumstances of each case.

For more information on the registering of deaths, refer to Key Elements in the Process: Registering of deaths.

Funeral Directors

Funeral directors help families and friends of deceased persons to lay their loved ones to rest in a respectful and dignified manner. Family members are welcome to contact a funeral director to arrange care for their loved one at any time. Once the coroner has gathered all the information they require from the deceased person’s body, they will sign a certificate authorising release of the body. If the coroner’s court is aware that family members have contacted a funeral director, then the mortuary staff will call the funeral director when the deceased person is ready to be collected. The coroner’s court will call the senior next of kin and let them know, so the funeral director may also be contacted by families to request that the deceased person be collected. If a family contacts a funeral director, they will liaise with the mortuary to transfer the deceased person into their care as soon as practicable.

For more information, refer to A Guide for Families and Friends: Practical matters and A Guide for Families and Friends: Who can help?.

Information for funeral directors

  • The deceased person cannot be collected from the mortuary until the coroner signs a certificate authorising their release.
  • If the coroner is notified that you have been contracted to care for the deceased person, then mortuary staff will contact you as soon as the body is ready to be collected.
  • The senior next of kin will be notified by the court once the certificate authorising release is signed, so they may also choose to notify you.
  • The coroners’ office will be able to provide guidance on when the deceased person is likely to be released for burial or cremation.
  • The coroner will have named the senior next of kin at various stages in the investigation. The coroner’s decision on who is the senior next of kin has no bearing on any legal proceedings outside the coroner’s court. If there is a disagreement about to whom the body should be released, parties should apply to the Supreme Court under probate law.
  • All medical procedures are undertaken with the aim of returning deceased persons to families for cremation or burial as soon as is reasonably possible.
  • Once a deceased person is released by the coroner, there are no additional restrictions placed on cremation, manner of burial or location of burial by the coroner (over and above the usual Tasmanian laws surrounding burial and cremation).
  • Police will take all the personal effects belonging to the deceased person. If any family member or close friend is seeking return of these items, advise them to contact the coroner’s court.

Insurance companies

Insurance companies may be involved in coronial proceedings for a number of reasons. These include matters where there has been motor vehicle damage due to a fatal crash, matters involving superannuation and matters where insurance claims are made relating to deceased persons (such as payouts for life insurance). Insurance companies may be granted access to a particular coronial document if they have a ‘sufficient interest’ in that document. For example, if an insurance company genuinely needs to know the cause of death they can notify the coroners’ associates of their interest in the matter. Once the coroner’s findings are ready, they will release a copy to the insurance company. It is not possible for the coroner to issue a ‘preliminary’ or ‘draft’ finding before the investigation is complete.

It is common for an insurance company to have a sufficient interest in one document to receive a copy. Insurance companies rarely have an interest in relation to an entire investigation. Although their interest in a matter is enough to allow access to some documents, it will not usually give them the right to question witnesses in court and exercise other rights of an ‘interested person’. In some cases, the coroner will take custody of an item (such as a motor vehicle) as evidence during an investigation. All items held as evidence remain in the custody of the coroner until they make an order as to care and control, or until the findings are handed down, whichever occurs first. If a coroner does make a care and control order (s 60) the item can be returned, however it remains in the custody of the coroner and so it must not be altered or disposed of until the findings are handed down. For example, if an order is made returning a laptop, the laptop cannot be sold or any files deleted.

Insurance company representatives are asked to note that the coroner does not issue Death Certificates. A coroner will make findings as to cause of death, but Death Certificates can only be sourced from Births, Deaths and Marriages (via Service Tasmania). If a bank or other institution requests a ‘death certificate from the coroner’ you should clarify whether they are requesting a copy of the ‘coroner’s findings certifying cause of death’, or whether they are requesting the ‘Death Certificate’ from Births, Deaths and Marriages.

For more information on how to apply to Service Tasmania for a copy of the Death Certificate, refer to Key Elements in the Process: Documents.


The media play an important role in coronial proceedings, conveying the coroner’s findings into the public arena. It is through media reports that most people become aware of coronial findings and therefore, it is through the media that inquests and findings can make their most significant impact on the public. One of the coroners’ most important roles is to protect the public, and therefore the coroners’ office works with the media so that the public is made aware of coroners’ comments, warnings and recommendations, and their knowledge and wellbeing are increased.

The media can also play an important role for families. If the families and friends of a deceased person feel that the death of their loved one could have been avoided, the public naming of any authorities that may have contributed to the death can have a positive emotional effect. People feel that their voice has been heard and this can help them to cope. The death of a loved one is a tragic event and the knowledge that others have been saved this pain can be a comfort in difficult times.

Information for the media

  • All coronial inquests are open to the public and the media, unless the coroner orders otherwise. The coroner has the power to exclude a person from court for a part or all of the proceedings, although this does not often occur.
  • You are welcome to make notes during inquests including direct quotes; however, you may not record sound or images anywhere in the court building.
  • The staff at the coroners’ office are always pleased to assist by providing court dates and information on the status of an investigation where appropriate.
  • You may apply to access documents on the court file using the ‘Application to Access Coronial Records’  form on the Magistrates Court web site, under Forms. Access may be granted where you, or the organisation you work for, has a ‘sufficient interest’ in the document in question.
  • All information disclosed during an inquest can be published unless a coroner makes an order restricting the publication of proceedings (or evidence tendered at an inquest) in whole or in part. There are penalties for publishing materials restricted in this manner.
  • The factors which a coroner will take into account when determining any application to restrict or prohibit publication are, whether publication would:
    • be likely to prejudice the fair trial of a person
    • be contrary to the administration of justice, national security or personal security
    • involve the disclosure of details of sensitive personal matters including, if the senior next of kin of the deceased has so requested, the name of the deceased.
  • Some coronial cases are highly sensitive and care must be taken in reporting these matters in a suitable manner. In particular, when reporting on cases where suicide and mental illness are factors, the following document should be consulted: Reporting Suicide and Mental Illness: a Mindframe resource for media professionals. This resource is available free on the Mindframe web site under ‘For media’.
  • Coronial findings are often published, and when this occurs they are made available for public viewing on the coroner’s court section of the Magistrates Court web site, under Coronial Findings. Findings made after an inquest are always published online.