Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Death of a Child - Reporting a death to the Coroner

  • Role of the Coroner

    The coroner is a judicial officer who is responsible for the independent investigation of reportable deaths (and fires), with the objective of reducing the number of preventable deaths (and fires) and promoting public health and safety.

    In an investigation into a death, the coroner must find, if possible:

    • the identity of the deceased person
    • the cause of death
    • in certain cases, the circumstances in which the death occurred

    The coroner may or may not direct that an autopsy be held. Next of kin can request that the coroner does not direct an autopsy, but the coroner has the final say in this.

    The coroner may or may not direct that an inquest be held. An inquest is a more detailed investigation including a public hearing.

    When must you report a death?

    If, having read this, you are still uncertain if you need to report you should complete a copy of the form you will find here and fax it to the Coroners Office. Once the form has been received by the Initial Investigations Office (IIO), it will be presented to the Duty Coroner for determination as to whether the death is reportable or not. 

    Once a decision has been made, the medical practitioner making the enquiry will be contacted and advised of the coroner's decision.

     
    Please place a copy of the completed form in the medical record and forward a copy to the Medicolegal Department.

     Call 1300 309 519 to speak to the Coroner's Office.

    A doctor must report a death to the coroner as soon as possible if any of these conditions apply:

    • the death was unexpected;


    • the death was violent or unnatural;
      • For example, homicide; suicide; drug, alcohol and poison related deaths;

     

    • the death resulted, directly or indirectly, from an accident or injury
      (even if there is a prolonged interval between the incident and death);
      • For example, drownings; deaths caused by a traumatic event such as a motor vehicle accident or a fall resulting in complications such as a fractured neck of femur or subdural haemorrhage
         
    • the death occurs during a medical procedure or following a medical procedure where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death
      • Please see explanation below.

    • a Medical Certificate of Cause of Death has not been signed and is not likely to be signed;
      • For example, where an opinion about the probable cause of death cannot be formed

     

    • the identity of the person is unknown;


    • the death occurred in custody or care of the state

     

    • the person was a patient within the meaning of the Mental Health Act 1986;

     

    • the death is a reviewable death because it is the second or subsequent child of either of the deceased child's parents
      to have died (more detail).

     

     

    Reportable deaths associated with medical procedures 

    A death is reportable under this category if it meets BOTH of the following two criterion:

    Criteria One - the death occurs during a medical procedure; or following a medical
    procedure where the death is or may be causally related to the medical procedure

    Criteria Two - a registered medical practitioner would not, immediately before the procedure was undertaken, have
    reasonably expected the death

    In determining whether the death meets Criteria One, the medical practitioner should consider the
    following questions:

    • Would the person have died at about the same time if the medical procedure was not undertaken?
    • Was the medical procedure necessary for the person's recovery, rather than optional or elective?
    • Was the medical procedure carried out with all reasonable care and skill?

    If 'no' to any of the above (and the death meets criteria two) - the death is reportable.

    • In determining whether the death meets Criteria Two (above), the medical practitioner should
      consider the following questions as a reasonable competent health practitioner ( definition) of that kind would:
      Before the medical procedure was performed, was the person's condition such that death was foreseen
      as more likely than not to occur?
    • Was the decision to perform the medical procedure reasonable given the person's condition including
      their quality of life?

    If "no" to any of the above (and the death meets criteria one) - the death is reportable.

     

    Back to Death (procedures)

    A 'reasonably competent practitioner of that kind' should be an ordinary skilled practitioner exercising and professing to have the capabilities required in the particular field of medical practice under consideration; who hypothetically would possess information about all relevant matters including: the person's known state of health before the medical procedure was performed, the clinically accepted range of risk associated with the medical procedure, etc.

    Return to description of reportable death

    What is a reviewable death

    Under the Coroners Act 2008, the death of a child is a reviewable death if the deceased child is the second or subsequent child of either of the deceased child's parents to have died. Such a death must be reported to the State Coroner by a medical practitioner (who was present at or after the death of the child) or any person who has reasonable grounds to believe that it has not been reported.

    The State Coroner then has discretionary powers in relation to further investigation and/or referral to the Victorian Institute of Forensic Medicine. If deemed appropriate, the Family and Community Support Service of the court will contact the family. The death of a second or subsequent child of a parent will not be considered a reviewable death if the death occurs in a hospital and the child was born at a hospital and had always been an in-patient of a hospital7 (and the death was not also a reportable death)

    Return to reportable deaths