Main Navigation

You are here:

Health Professionals

The review of unexpected deaths in patients is an important part of the role of the Coroners Court. This section is designed to assist health professionals engaged in the coronial process.

Published findings from cases relating specifically to health and medical care related issues can be found in the Health and Medical Findings table.

Reportable and Reviewable Deaths

The Coroners Court oversees the investigation of 'reportable deaths', which are deaths where the cause of death is unclear, unexpected or secondary to trauma (including falls), or follows a medical procedure or adverse event. Such deaths may occur in the community, during transport to hospital, in the setting of an admission or following discharge and must be referred to the Coroner.

The Coroner also oversees the investigation of 'reviewable deaths', which are a category of reportable deaths that involve the second of subsequent death of a child to a parent (excluding stillborns).

All patients detained under the Mental Health Act, in custody or under the care of the Department of Human Services including individuals living in residential care at the time of their death must be reported to the Coroner - even if their death is expected and appears unrelated to their 'in care' status.

Detailed information for health professionals is available below.

Information for Health Professionals

Reportable and Reviewable Deaths Flowchart

To report a Reportable or Reviewable Death, please ring 1300 309 519 and ask to speak to Coronial Admissions and Enquires.

Failure to Report a Death

Medical practitioners have a legal obligation to report a reportable or reviewable death under the Coroner Act 2008.

It is imperative that the Coroner is notified as soon as possible in order to liaise with the family regarding possible autopsy, prevent the removal of medical devices such as central lines, surgical drains and endotracheal tubes from the deceased and to ensure that important medical specimens such as antemortem blood or tissues samples (including placentas) are not discarded.

Delayed recognition of a coroners case can lead to significant distress for the deceased's family, and serious consequences for the professionals involved and the integrity of the investigation.

Penalties for failing to report a reportable case

To report a Reportable or Reviewable Death, please ring 1300 309 519 and ask to speak to Coronial Admissions and Enquires.

Resources for Families

Printable brochures and summaries suitable for family members outlining the Coroners Process are available in the Publications section of this website under the Brochures & Books section.

Quick link:

Making a Statement to the Coroner

Writing a statement for the Coroner may be daunting.  A practical guide to assist individuals providing a statement is available below.

Guidelines for writing a statement for the Coroner

Your medical indemnity insurer or hospital legal counsel may be able to assist you in the preparation of your statement.

Attending an Inquest

Some investigations require an inquest.  An inquest is unlike other court cases. It is an inquisitorial process rather than adversarial. In other words, an inquest is not a trial, with a prosecutor and a defendant, but an inquiry led by a coroner that seeks to find out why the death occurred.

The In The Courtroom section provides further information about the nature of a Coronial Inquests and outlines court etiquette.

Quick link:

Information for Expert Witnesses

Health and medical professionals may be approached to provide an independent expert opinion regarding a case before the Coroner. Further information for expert witnesses is available below.

Information for Expert Witnesses

Finding  Information about Cases

The Findings (or conclusions) of individual cases are publically available and published online on the Coroners' Written Findings page.

Written Findings relating to themes in health and medical cases can also be searched by management and systemic issues using the Health and Medical Case Search page.  This aims to bring health and medical cases with similar issues together.

Information for people who wish to contribute to an open case or obtain more detailed information about a completed case as an Interested Parties (family members, carers or other parties such as health professionals directly involved in a case) can be found on the Interested Parties page.

In addition to the Written Findings published by the Coroner, additional data about health and medical related deaths is collected and used by the Coroners' Prevention Unit to analyse deaths in Victoria and assist the Coroner in the development of recommendations.  A list of the Coroners' Prevention Unit's reports and publications is available on the Publications page.

Other Concerns about Care Provided

Families and carers may have concerns about the provision of care to their loved one. Some of these concerns fall outside of the jurisdiction of the Coroner, whose primary role is to investigate deaths to identify opportunities to prevent similar deaths and adverse events occurring in the future.

Other concerns and complaints about the service provided may be directed to the health professional or health service involved. Unresolved complaints or concerns may be referred to The Office of the Health Services Commissioner.

Serious concerns about the professional behaviour of medical, nursing and allied health staff may also be directed to The Australian Health Practitioner Regulation Agency, which oversees the registration of health professionals.