Coronor reports

Reading a Coroner report, I sometimes feel part voyeur with a macabre interest but feeling guilty about invading someone’s death. However, I reconcile that by using a Coroner’s report as a way of learning. With my medical education, as I read the story unfolding, I sometimes think to myself. “no, no no, check the blood pressure”, or “He is clearly septic and the temperature means nothing. Give the antibiotics, Get him to ICU – now!” It is like when you watch a horror movie and the teenagers split up look around the haunted house alone. “No you stupid fools stay together”, except these are real people falling through the gaps and being harmed. I sometimes place myself in the deceased story and think would I have done that, omitted this? “If only…”

The office of the coroner dates from approximately the 12th century under the English judicial system. In its early years, the coroner’s duties were mainly administrative. The coroner kept the king’s records, and collected revenue. Over the years the role expanded to include investigating deaths. If a person was found dead the coroner was notified and a jury was assembled where the jury examined the body. Evidence was heard and the jury’s verdict taken. If a verdict of murder or manslaughter was returned the coroner seized his property for the king. For a discussion of the the early history of the coroner, this article by Charles Gross is informative. In Australia, the Coroner’s jurisdiction has been in place since the foundation of the NSW colony. In his commission of 2 April 1787 Governor Phillip was granted power to ‘constitute and appoint Justices of the Peace, Coroners Constable and other necessary officers’. The earliest recorded inquest in New South Wales dates from 1796 in which three magistrates including Samuel Marsden inquired into the death of a convict who had been shot.

Today, a Coroner investigates a death in order to determine the identity of the deceased and the date, place, circumstances and medical cause of death. It is stated that the Coroner’s role is to find out what happened, not to point the finger or lay blame.  To assist a Coroner will call upon experts in the field, police, and witnesses, including doctors and nurses who may have been involved in a deceased person’s care. Importantly, not all people who die are investigated by the Coroner. And sometimes findings are not disclosed to the general public. The Coroner after deliberation will makes recommendations to prevent the same think happening again, that is to avoid a preventable death. In the past I have seen arguments about how impractical some of these recommendations are. For example,  one Coroner suggested GP’s should not prescribe fentanyl, which was an interesting statement to make when an non-GP had prescribed the medication that lead to the person’s death. Some reports are more controversial than others. Newspapers have the habit of summarising a Coroner’s report to sell a story, so journalist’s reports should never relied upon to make an opinion without reading the original report. The Inquest into the death of Hamid Khazaei recently completed by the Queensland Coroner, Terry Ryan provides so much more than what can be gleaned from various newspapers. As there is a delay between death and the Coroner’s recommendation, the media may speculate all sorts of stories. A Coroner report can provide closure to family and friends of the dead person.

I have been involved in the death of a number of patients whilst working within the hospital system and had to present evidence to the Coroner in one case. That information is all on public record. Back in October 2002, a man fell from his bed in hospital and died shortly afterwards from a massive intracranial haemorrhage. I was the intern on the team looking after him on that final admission. Reading back through the Coroner’s report today, I can see essentially how all the holes in the Swiss cheese lined up which lead to a preventable death.

To ensure that the as many as possible are informed of coroner recommendations, many reports are available for reading. Of course, some of these reports pertain to deaths due to violence, misadventure and have no medical staff intervention at all.

If you have an interest, here are the links to public Coroner reports.


(to see coroner reports, type “coroner” into text search)

New Zealand

Northern Territory



South Australia




edit 9/10/18

The Clinical Communiqué is an electronic publication containing narrative case reports about lessons learned from Coroners’ investigations into preventable deaths in acute hospital and community settings. The Clinical Communiqué is written, edited, published and distributed by the Department of Forensic Medicine, Monash University and the Victorian Institute of Forensic Medicine.

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