Coronial investigations and inquests

• Always contact Avant before providing a signed statement or having any detailed conversations with the coroner or police on the coroner's behalf.
• If you receive a summons to give evidence at a coronial inquest you should contact Avant immediately so that we can assist you in the process.
• Coronial investigations can be lengthy and stressful – even if there is no criticism of your care. Make sure you seek support.

Many medical practitioners find themselves involved in coronial proceedings at some stage in their career. Coroners often seek statements from medical practitioners when investigating 'reportable deaths'.

The legislation in each state and territory defines a 'reportable death' somewhat differently however it will usually include accidents and suicides, as well as violent, unnatural or unexpected deaths. This can include deaths after medical care has been provided. It can also include deaths that occur in care or in custody.

The coroner’s role is to determine the identity of the deceased as well as when and where they died and the circumstances and cause of death.

The coronial process often involves reviewing all aspects of care and clinical decisions leading up to the patient’s death. Reviews of the majority of deaths referred to the coroner are finalised without needing a formal inquest. However, the process can lead to civil or disciplinary action or even criminal proceedings if the coroner is critical of the care provided. Coroners may also make recommendations to governments and other agencies with a view to improving public health and safety.

The police generally conduct the preliminary investigation and gathering of evidence for the coroner is generally conducted by the police under the coroner’s instruction.

Providing a statement for the coroner

You may become involved in the coronial process if you provided medical care to the patient before they died. The police or coroner may approach you to provide verbal information or with a request for a formal legal statement.

We strongly recommend you contact us as soon as possible and before you provide any statement or have any detailed conversations with police, even if you feel confident there will be no questions about your care. Statements are requested at the early stage of an investigation, when it may not be clear what all the issues are going to be and what the autopsy and investigative reports will show. It is important you don’t inadvertently compromise your rights. It is perfectly acceptable to say you are willing to assist once you have spoken to your medical defence organisation or indemnity insurer.

Even if the death occurred in a hospital setting and you are indemnified by the hospital, we still recommend you contact us. Our role will be to support you through the process and ensure your interests are protected.

We assist our members with this process. It is our usual practice to cooperate with the coroner’s request and the police during the investigation process by assisting and advising you on how to respond. For example, it is not advisable for you to comment upon the care provided by other medical practitioners in your statement – concentrate on your involvement in the matter. Further guidelines on how to construct a statement are available in our factsheet: Avant How to write a coronial statement.

Once those assisting the coroner have obtained statements from the relevant witnesses, they may seek an independent expert report commenting on the role of the various individuals in the care and treatment of the deceased.

End of the investigation

The coroner will review all the evidence and determine whether an inquest (a court hearing) is necessary.

If the manner and cause of death are clear, the coroner will usually dispense with an inquest. A great majority of coronial proceedings are finalised by the coroner without the need for an inquest.

If, however at the end of the investigation, the manner and cause of death remain unclear, the coroner will usually hold an inquest. Coronial investigations and inquests can be complex and lengthy.

Medical practitioners may be asked to give evidence at inquests for a variety of reasons. Often the practitioner’s involvement is not contentious. They simply possess one or two pieces of the factual jigsaw puzzle that the coroner needs to assemble. We will help you appreciate the nature and the extent of your involvement as the case progresses.

If you have provided a statement to the coroner and an inquest is held, it is likely that you will be summoned to give evidence at the inquest. Occasionally, you may be asked to attend court to give evidence at short notice. This may be because it is not until the inquest commences that it becomes clear that further evidence is needed. In either case you should contact us immediately so that steps can be taken to ensure your interests are protected.

When you request assistance, we will advise you on your position and whether you need to have legal representation at the inquest. If we appoint a lawyer to represent you, the lawyer will contact the coroner’s court advising that they will be seeking leave to appear for you at the inquest.

The investigating officer will put together a brief for the coroner that contains all relevant statements, medical records, autopsy reports and expert reports obtained by the coroner during the investigation. Your lawyer will obtain a copy of the coronial brief and review it to identify possible areas for adverse comments that the coroner may find.

If you are called to give evidence, you will be asked to adopt or confirm the statement you have previously provided. Those people who have an interest in the matter are then entitled to ask questions in cross-examination. Generally, at the end of questioning, your lawyer will ask you questions to clear up any ambiguities or issues that may have arisen. People called to give evidence are either factual witnesses or expert witnesses. 

An inquest is a fact-finding exercise, and not a method of apportioning blame. 

Inquest hearing time can vary from days to many weeks depending on the complexity of the case and the number of witnesses. Generally, we will be notified of the amount of time the inquest is ‘set down’ for. Regardless of the duration of the inquest, as a witness, after you give your evidence (which may range from a few minutes to a day or two) the coroner will excuse you from attending again. 

The result of a coronial inquest

After the inquest the coroner will hand down their findings and sometimes make recommendations. Although it is not a court of blame, sometimes coroners may be critical of a medical practitioner and refer them to a disciplinary body such as a state health care complaints body or Ahpra. The complaints body or Ahpra will follow a separate process to assess or investigate the practitioner’s conduct.

The coroner may form the view that there is a case for criminal charges to be brought against an individual. If so, the coroner will suspend the inquest and forward the documents to the director of public prosecution. Fortunately, this is a rare event for medical practitioners.

After the coroner has handed down their findings, the deceased's family may consider bringing a compensation claim alleging negligence and seeking damages against individual practitioners.

Inquests are generally open to the public and sometimes attract publicity. We recommend you do not speak to the media about the matter as this may prejudice not only the coronial proceedings but any subsequent proceedings or disciplinary investigation.

Coronial investigations often take more than a year for the evidence to be gathered, and the process can be drawn out and stressful. At the inquest the patient’s family are likely to be distressed and seeking answers. These factors can compound the significant emotional impact of a patient’s death and are important reasons to make sure you are supported through the process. We can support you by:

• being the point of contact for the police and the coroner’s office
• ensuring you have all available material and helping you to draft coronial statements
• reviewing your statement from a medical and legal perspective to help you provide an accurate report while not inadvertently compromising your interests or your rights
• providing peer medical support
• advising and assisting through the investigation
• representing you at inquest
• connecting you with our Personal Support Program on 1300 360 364 or Doctor’s Health Advisory Service if required.

Note: Assistance to Avant members is subject to the terms, conditions and exclusions of the policy

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.