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Coroner's Prevention Unit

The Coroners Prevention Unit is a specialist service for coroners created to strengthen their prevention role and provide them with expert assistance by:

• reviewing a range of reportable and reviewable deaths
• collecting and analysing data relating to reportable and reviewable deaths
• assisting coroners in the development of prevention-focussed coronial recommendations
• monitoring and evaluating the effectiveness of coronial recommendations.

The central goals of the Coroners Prevention Unit are to:

• improve the quality and applicability of coronial recommendations
• increase the uptake and implementation rate of coronial recommendations
• contribute to the reduction of preventable deaths in Victoria.

The unit plays an important role in improving the health and safety of the broader Victorian community.

Where does the Coroners Prevention Unit fit within the coronial process?

The Coroners Prevention Unit may contribute at any stage of the coronial process, including:

When a death is initially reported
Through the provision of expert advice that can be used by coroners to: decide on the direction of the case investigation; ensure that essential data is gathered; and identify any prevention opportunities relevant to an individual case.

When recommendations are being developed
Through the provision of expert advice to coroners on the nature and extent of causes and risk factors; up-to-date evidence on countermeasures; identification of relevant stakeholders who may be affected by the recommendations; information on relevant sections of legislation, standards and codes of practice; and information on similar previous cases and recommendations.

When recommendations are being finalised
Engaging with relevant stakeholders at the direction of coroners to ensure that any proposed coronial recommendations are reasonable, viable and likely to be effective.

After recommendations have been made
Monitoring and collecting information on the response to and implementation of coronial recommendations.

Additionally, the Coroners Prevention Unit undertakes both individual and collaborative research projects to generate a better understanding of preventable deaths in Victoria and identify intervention opportunities.

Coroners Prevention Unit investigation teams

The Coroners Prevention Unit comprises several distinct investigative teams who gather and provide expert information on particular types of deaths.

Unintentional Death Investigation Team
Assists in the investigation and development of recommendations surrounding unintentionally caused deaths. For example, drownings, fires, electrocutions and transport-related fatalities.

Intentional Death Investigation Team
Assists in the investigation and development of recommendations surrounding intentionally caused deaths. For example, suicides and assaults. This team also oversees the Victorian Systemic Review of Family Violence Deaths. As part of the review, family violence related deaths investigated by coroners are examined to inform future interventions aimed at
protecting children and adults from family violence.

Clinical Liaison Service Team
Assists in the investigation and development of recommendations surrounding deaths occurring during the provision of healthcare. They assist in identifying factors that may help improve patient safety and risk management in such settings.

Operational Team
Undertakes specific and targeted projects; develops policies; captures, codes and analyses data.