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Coronial investigations and inquests

Coronial investigations and inquests

Philip Gardner, Special Counsel, Gordon Legal.

In your careers as nurses, midwives, or carers there’s a chance a patient will die unexpectedly, during or after a medical procedure or at a health/aged care facility.

These deaths must be reported to the coroner, who then notifies police. The police will investigate what happened on behalf of the coroner. This means you could be interviewed. It’s important you understand this is a standard practice and doesn’t automatically mean somebody has done something wrong.

What happens when there’s a reportable death?

Your health/aged care facility will have a procedure to follow in the event of such a death.

Usually, a medical or senior staff member is nominated to contact the Coronial Admissions and Enquiries office to report the death on 1300 309 519. Mental health service providers are also required to notify the chief psychiatrist of reportable deaths.

The responsible staff member will be requested to complete a medical deposition and a statement of Identification form with a family member of the deceased. Family members should be supported in accordance with facility policy. Families can also receive support and guidance about the process from the Coroners Court of Victoria.

If you witness anything about a reportable death that could be contentious or the person died when you were directly responsible for providing their care, then you should immediately contact ANMF for a referral to Gordon Legal.

We can help you through the entire process, from making a statement to appearing at the Coroners Court.
Gordon Legal has an office at the ANMF (Vic Branch) headquarters, 535 Elizabeth Street, Melbourne, where legal services in these situations are a membership benefit.

Requests for statements

Nurses, midwives and carers are regularly requested to prepare a statement about the circumstances of a reportable death. The request may be made by the employer, the police on behalf of the coroner or, in rare circumstances, by solicitors acting for an interested party.

Before completing and providing a statement you should contact Gordon Legal through ANMF to discuss the matter. You should not assume that your interests as an employee coincide with those of your employer or those of other health professionals involved in delivering care to the deceased. You cannot be compelled to provide a statement at the time of a death.

Providing a statement

Gordon Legal can help you prepare a statement. There are some key things to know about giving statements:

  • The statement will generally only contain factual information, not your opinion, regarding what happened.
  • Generally, you will only be providing information about events that you directly witnessed, although occasionally you may have to summarise the care given by other staff.
  • You will have to refer to the medical records of the deceased person (e.g. admission dates and details, procedures performed) .
  • You may have to refer to the policies and procedures of the health/aged care facility and attach these to your statement.
  • If you cannot access copies of either the medical records or policies and procedures of the healthcare facility, contact Gordon Legal or the Coroners Court.
  • The statement must be given before the due date specified in the request. You may be able to ask for an extension in some cases.
  • Your statement may be read by the family of the deceased, lawyers of interested parties and the coroner.

Appearing at the Coroners Court

The coroner is a court-like body that investigates all deaths in Victoria.

A small number of investigations proceed to hearings, called inquests. If an inquest is held you may be called as a witness.

If you have been summoned to attend an inquest, please contact Gordon Legal immediately. However, there are a few key things to know about appearing at an inquest:

  • You may be asked questions by the coroner or lawyers from interested parties (like the deceased’s family or the healthcare facility).
  • A coroner can require you to answer questions, even if your answers may be incriminatory.
  • If you have concerns that your answers may be incriminatory, please raise these concerns with Gordon Legal before giving evidence.

Coroner’s findings

Following an investigation, the coroner will make a written finding which will include:

  • the identity of the deceased
  • the time, date, and location of the death
  • the cause of death.

They may also include:

  • a summary of evidence relating to the circumstances of the death
  • comments or recommendations aimed at preventing similar deaths.

The coroner can refer findings critical of a healthcare provider or healthcare professionals to relevant bodies such as the relevant government Minister, hospital board or the Australian Health Practitioner Regulation Authority.

PLEASE REMEMBER:
Gordon Legal understands the processes and is ready to help you comply with your obligations while protecting your rights when it comes to a reportable death.

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