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 see below heading 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 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 affidavit 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 an affidavit to aid the investigation. You are not required by law to provide a written affidavit. 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.

Registering of deaths

Under the Births, Deaths and Marriages Registration Act 1999 s 35 (1), 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,

must, within 48 hours after the death, notify the Registrar of Births, Deaths and Marriages (BDM) of the death and of the cause of death in a form approved by the registrar.

This notice / form is called a Medical Certificate of Cause of Death (MCCD). The medical practitioner need not give notice to the registrar if a coroner or a police officer is required to be notified of the death under the Coroners Act 1995 (i.e. if the death is reportable).

If a police officer or the coroner is notified of a death under the Act, then a coronial investigation begins. If, after medical examinations, the coroner determines that the death was in fact the result of natural causes, they will issue a letter notifying the senior next of kin of this and informing them that the coroner’s jurisdiction is at an end and the investigation will cease as soon as is practicable. This letter will also be sent to any other family members who request to be kept informed.

If the result of the medical examination is that the death continues to be in the category of reportable deaths, then the investigation continues. If the coroner is involved, then the registrar of BDM is notified of the death by the coroners’ office through a Registration of Death Statement, which is generated from the initial police report. The registrar will register the death and BDM can issue an interim death certificate, which will state that the coronial investigation is still ongoing.

Section 28(1)(e) of the Act requires coroners to find, if possible, the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999 (Tas). At the time of publishing the Handbook, there is no legislation stating which particulars are required to register a death. The coroners are thus not legally required to record specific particulars. The practice of coroners is to only record the personal particulars which may be appropriate in the circumstances of each case. Other details about the deceased person, their family members and their life will often be recorded in the findings; however, they will not usually be stated separately in the section of the findings that deals with the registration of the death.

Some of the details that a coroner may record in their findings are:

full name (including any previous legal names if known)
last residential address
place of birth
date of birth (or if not known, age at date of death)
sex (male / female / X)
date of death
place of death
whether of Aboriginal or Torres Strait Islander descent (or both)
if 18 years old or over - whether, immediately before death, the deceased person was married, in a significant relationship (Relationships Act 2003), divorced, widowed, in a de facto relationship or single
if 15 years old or over - the usual occupation before death and whether or not the deceased person was a pensioner or was retired immediately before death
the full names, sex and date of birth (or age) of any children (including any children who are deceased)
and any such other information as the coroner deems reasonably necessary to provide an accurate and complete picture of that person’s death.

full name (including, if applicable, the original surname) of current or former spouse

Under section 36 of the Births, Deaths and Marriages Registration Act 1999, the coroner must also provide the registrar with a copy of the certificate of burial issued for the deceased person as well as the cause of death, when they become available. Once this occurs, BDM will finalise the registration and can issue a standard death certificate.

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.

A Health Practitioners Guide for Writing a Statement for the Coroner

This guide has been created to assist health practitioners when requested by the Coroner to provide a statement.

A Health Practitioners Guide for Writing a Statement for the Coroner

Circular to Hospitals, Medical Practitioners and Health Professionals

This circular has been created to assist Hospitals, Medical Practitioners and Health Professionals when reporting a death that is 'reportable'.

Circular to Hospitals, Medical Practitioners and Health Professionals

Death of Aged Care Residents

This information sheet applies to older persons who are residents (either temporary or permanent)
of any residential care facility.

Death of Aged Care Residents

Last updated: 16 July 2024