What to do when the coroner calls

Coroner (Hero Image)

Healthcare practitioners, mostly medical can potentially be involved in coroner's court matters. There are typically two reasons for this:

  1. The requirement to make a reportable death
  2. You have been asked to prepare a statement/report and appear as a witness

Of course, you may have to do both of these things connected with the death of the same patient.

Reportable deaths

The threshold for making a reportable death is very high. Each coroner’s court has its own state/territory jurisdiction so what qualifies as a reportable death varies slightly in each state and territory. If you are unsure if a death is reportable, you can contact MIPS for advice.

In general terms, you are obliged to make reports if you are the doctor responsible for a person’s medical care immediately before death, or who examines the body of the deceased person after death. You will need to make a report if:

  • your patient has suffered a violent, unnatural or unexpected death such as homicide, suicide or death induced by drugs, alcohols or poison – regardless of whether it was deliberate or accidental.
  • your patient has died by accident. For example, road or public transport fatalities, accidental falls, workplace deaths, electrocutions, drownings and animal attacks. This even applies where there is a prolonged interval between the accident and death.
  • the identity of your patient is not known.
  • cause of death of your patient is not known (ie you cannot form an opinion about the probable cause of death and therefore cannot sign a death certificate).
  • our patient dies unexpectedly during or after a medical procedure, or other unexpected or accidental deaths in a healthcare facility.
  • a death notice was not signed for your patient and is not likely to be signed.

Preparing statements and appearing as a witness

First and foremost, you should notify MIPS of any involvement and seek our assistance.

MIPS membership includes assistance in preparing appropriate statements and guiding you through the coronial process. This includes advice and representation from solicitors and MIPS clinical advisers. 

In some cases, a Coronial inquest can impact on the likelihood of a common law action arising from the death. In extreme cases Coroners have referred concerns about a practitioners healthcare to AHPRA for further investigation. 

Coroners investigate thousands of deaths each year, however, only a small number (about 5%) proceed to a formal inquest.

If there is an inquest, doctors are sometimes called as either witnesses, for example if you were the treating practitioner who reported the death, or as an expert witnesses to comment on the nature of the death. The following video scenarios illustrate how this would unfold if you were called as a witness.

Scenario 1 - Doctor contacts MIPS after receiving a request from police (3:08)

Scenario 2 - Doctor prepares to give evidence in a Coroner's inquest (2:54)

Scenario 3 – Doctor is cross examined in Court by a barrister (3:09)

Scenario 4 – Repercussions. The Coroner’s findings (4:12)

Each Coroner’s Court has good information online about the coronial process and your obligations as a healthcare practitioner. See the coronial process - Coroner's Court of:


Related on-demand education you may be interested in

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Various techniques discussed to help you deal with difficult colleagues, employment related issues and industrial disputes, performance, assessment and competency issues, practice staff difficulties and mandatory reporting.

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The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided. Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 or education@mips.com.au for specific advice.