Coroners are responsible for investigating reportable deaths under the Coroner’s Act 2003, including any death that is considered to be ‘health care related’ – that is, where the health care (or a failure to provide health care) caused or contributed to the death, and the death was an unexpected outcome.

Certain reportable deaths (for example, deaths in custody) must be the subject of an inquest, and other reportable deaths may be the subject of an inquest if the Coroner considers that an inquest is in the public interest. Coroners fairly frequently do consider that it is in the public interest to hold an inquest into an unexpected deaths arising out of the provision of health care.

Involvement at some level with the Coroner’s Office is accordingly a reality of life for many health care practitioners, and in the course of their careers many doctors and nurses will have the experience of giving evidence in an inquest.

At times, that experience can be an uncomfortable one, especially where the family of a deceased patient is represented at the inquest and seeking evidence to support a claim for loss of dependency or nervous shock. The outcome of an inquest may have significant consequences for an individual medical practitioner.

When a death is reported, the coroner must ascertain the identity of the deceased person, how, when and where they died and the medical cause of death. The coroner may (and generally will) also comment upon relevant issues arising with respect to public health and safety, the administration of justice and how deaths may be prevented from arising in similar circumstances in future.

A coroner’s inquiry may be wide ranging, and is not limited by the rules of evidence that apply to a court proceeding. The purpose of the exercise is to determine the matters outlined above rather than to apportion blame.

However, if in the course of an inquest a coroner forms the view that an offence may have been committed, they must give details to the relevant prosecuting authority. A coroner may also notify an appropriate professional disciplinary body if he or she reasonably considers that the information may cause the body to inquire into the conduct in question.

Coroner’s findings accordingly can and do result in court proceedings in both civil and criminal jurisdictions (for example, the recently commenced criminal prosecution in relation to the abduction and murder of Sunshine Coast teenager Daniel Morecombe).

In the medical context, inquests and coronial investigations frequently result in (or at least are used to gather evidence for) compensation claims and referrals to professional disciplinary bodies. It is accordingly critical that health practitioners and the organisations that employ them obtain appropriate legal assistance in relation to health care related deaths that are likely to become the subject of an inquest.