The Coronial System and Determining Manner of Death in Australia -An Overview

Abstract

Death investigation in Australia was initially founded on the British coronial system. Today it continues to operate under a coroner-based service with each of the individual self-governing states and territories responsible for enacting and administering their own coronial legislation. This has led to some variation within Australia; however, there is broad similarity. Deaths reported to the coroner generally include those where the cause is unknown, there are violent/unnatural circumstances, the death is as a result of an anesthetic or medical procedure, the death occurred whilst held in care/custody, or the identity of the deceased is unknown. Coroners are legally qualified individuals who are appointed to administer the Coroners' Act, but have no medical training. They are required to investigate deaths to determine who a deceased person is, as well as, how, when, where and what caused them to die. This is an inquisitorial process with the purpose of determining the circumstances of death to serve the public interest. Their findings are presented in a written report that outlines the circumstances surrounding death in an attempt to indicate whether a death was natural or unnatural (due to external factors), and in the case of unnatural deaths, to outline the intent and external factors that led to death. Hence, the “manner of death” is presented as a narrative within the coroners' findings. The coroners use information obtained during their investigations to make recommendations about public health policy, justice, and the prevention of similar deaths in the future.

Keywords

Forensic pathology Death investigation Coronial system Australia Manner of death Coroner

Introduction

Australia is an island continent located in the South Pacific. It was originally established as a British penal settlement in 1788. When the American Revolution rejected the authority of Great Britain, this put an end to the transport of convicts from Britain to the now United States, which led to overcrowding of British jails. A decision was eventually made to send convicts to Australia, which was later expanded to include free settlers in the early 1800's. Under the Doctrine of Reception, being a British colony, Australia inherited English law. Hence, in early Australian history, Coronial law was inherited from England. The introduction of the Coroners Act 1887 [UK] made significant changes to the role of the coroner focusing more on determining the medical cause of death for the benefit of the community (1, 2). This was the advent of the modern coroner and removed some of their historical roles such as that of revenue collector for the crown.

The Commonwealth of Australia Constitution Act 1900 [Australia] (3), led to the formation of the Commonwealth of Australia whereby six independent British colonies officially became States in the nation of Australia. A federal system of government was formed, under which the powers were divided between the Federal and State governments. The Act declared that all of the States were to be self-governing and have their own system of courts and parliament (4). However, laws passed by the Commonwealth parliament would apply to the whole country and would override State laws where inconsistency existed. A decade later in 1911, the Northern Territory and Australian Capital Territory were handed back to the Commonwealth. Initially, laws for the territories were made by the Commonwealth, but legislation was later enacted to allow them to become self-governing territories (5, 6). In Australia, coronial law falls under the jurisdiction of individual states and territories; hence, each of the six states and two territories has legislated their own Coroner's Act (7 –14). In principal, the individual Acts are similar; however, there are some notable differences.

Discussion

The Coronial System in Australia

Today, Australia is a country of some 23.8 million people (15). A Registry of Births, Deaths and Marriages exists in each jurisdiction, and each of the states and territories has legislation mandating the registration of births and deaths. Nationwide in 2013, there were 147 678 deaths in Australia, of which around 13.2% were reported to a coroner. The remaining 86.8% were certified by an attending medical practitioner (16). Due to a number of factors, including variations in the Coronial Acts as well as vastly different environments and demographics, the number of reportable deaths varies significantly in different jurisdictions. For example, in 2013, 25% of deaths were reported to a coroner in the Northern Territory compared with 10.3% of deaths reported to a coroner in New South Wales (16).

A reportable death is one which meets the criteria to be investigated by a coroner as defined under the relevant Coronial Act (1). A coroner must be notified of a reportable death once a person becomes aware that a death is reportable (17). Although there is some variation in the definition of a reportable death between the state and territory legislation, in general terms, a death is reportable under the following circumstances:

Where the person died unexpectedly and the cause of death is unknown

Where the person died in a violent or unnatural manner

Where the person died during, or as a result of an anaesthetic

Where the person was ‘held in care’ or in custody immediately before they died

Where the identity of the person who has died is un known (16).

A reportable case must also fall under the physical jurisdiction of the Coroner who is planning to investigate (1).

An example from the Coroner's Act 2003 [Qld]:

(2)

A death is a reportable death if

(a)

the death happened in Queensland; or

(b)

although the death happened outside Queensland

(i)

the person's body is in Queensland; or

(ii)

at the time of death, the person ordinarily lived in Queensland; or

(iii)

the person, at the time of death, was on a journey to or from somewhere in Queensland; or

(iv)

the death was caused by an event that happened in Queensland [Sect 8(2)] (8).

From time to time, there is some overlap between jurisdictions, for example, where a death occurs due to an accident in one state, whilst the person ordinarily resides in another state. In these cases, there may be open discussion and agreement between coroners from the individual states to decide where a particular death is best investigated. The usual practice would be that the death is investigated within the jurisdiction in which it occurred; however, in some instances this may vary. The Acts also allow scope to investigate deaths that have occurred overseas or during travel to or from Australia by activating the residency clause.

Under the coronial system, the coroner is a legally qualified judicial officer responsible for the investigation of reportable deaths (18). Coroners do not possess any formal medical qualification. They operate within the legislation of their jurisdiction in order to perform these investigations. The legislation provides a broad scope for coroners to obtain and utilize information that is required to investigate a death. The investigation of a reportable death by the coroner will involve the police, forensic pathologists, forensic scientists, forensic medical officers, counselors, and a broad range of other professionals as required on a case by case basis (1). Notably, in the states of Victoria, New South Wales, South Australia, and Tasmania, and in the Australian Capital Territory (7, 10, 11, 13, 14) the role of the coroner also includes the investigation of fires, and in the Northern Territory, the coroner is responsible for the investigation of disasters (12).

Appointment of Coroners in Australia

The Attorney General in each state is responsible for enacting and overseeing legislation such as the Coroners Act and is responsible for formally appointing coroners. Larger states have a State Coroner who can make recommendations to the Attorney General regarding appropriate judicial officers to be appointed as coroners (2). For example, in New South Wales, to be appointed as a coroner, a person must be a qualified Australian lawyer (14). Coroners are usually legal officers who have progressed through the ranks as solicitors, barristers, magistrates, and/or district court judges. Usually they will have a background that is relevant to death investigation (1). However, in some jurisdictions, such as in rural regions of New South Wales, a magistrate is a coroner by virtue of office and they are overseen by the State Coroner. Many coroners are members of the Asia Pacific Coroners Society (APCS), which is a professional body to “promote the advancement, best practice and education of coronial law and practice” (19). The APCS holds an annual conference to facilitate professional development.

The Coroner's Investigation

Initially, when a death is reported to a coroner, there is early involvement of the police service (1, 18). In many cases, it will be the police who report the death to the coroner, having been advised of the death by a medical attendant, emergency services officer, the funeral attendant, or next of kin. In all Australian jurisdictions, it is the police service that is primarily involved with scene investigation. The initial police responders are often nonspecialist officers who collect specific information about the decedent, the circumstances of the death and the scene. This early collection of information is used to guide the coroner's investigation and determine if there are any suspicious circumstances surrounding a death (1, 18, 20). In cases that are deemed to be suspicious, specialized officers from specific forensic police branches will become involved. This would include scenes of crime officers and detectives. In some cases during this process, there may be concerning features or findings that the police are not qualified to assess (e.g., concerning marks on a body that are not clearly injuries). In these cases, a forensic pathologist may attend the death scene to give guidance as to their nature and etiology. The forensic pathologist is usually consulted for such opinion in suspicious deaths, deaths in custody, aviation accidents, and mass disasters where early input is deemed beneficial in guiding the investigation. In some instances, other professionals may also be sought for their opinion on certain matters. Examples of this would include aviation accidents in which an aviation expert, due to their area of expertise, would be best placed to comment on the findings at a scene or an anthropologist to guide exhumation of skeletonized remains (1).

The coronial investigation commences once a death has been reported to a coroner. The notification will be submitted in writing using the appropriate form, which may be a medical deposition in the case of a death in hospital, but is usually a police report. Initially, the coroner must determine if the death is a reportable death that requires investigation within their jurisdiction. If it is, the coroner is legislated to determine specific findings in relation to the death (1). An example from the Coroner's Act 2003 [Qld]:

(a)

who the deceased person is; and

(b)

how the person died; and

(c)

when the person died; and

(d)

where the person died, and in particular whether the person died in Queensland; and

(e)

what caused the person to die (8).

Taking into consideration the circumstances of the death and family views regarding autopsy, the coroner will determine the type of postmortem examination required. In many jurisdictions of Australia there is a move away from ordering a full internal postmortem examination in every case (18, 20 –22). The coroner has the right to issue a death certificate based on the information supplied; for example in the case of a medical deposition, without any further investigation. Some of the Coronial Acts have a provision for the next of kin to object to autopsy. In the state of New South Wales, a written objection from the senior next of kin (defined as the deceased's spouse, adult child, parent, adult sibling or executor of their estate) may be submitted, requesting a coroner not to order a postmortem examination (14). The coroner must then decide if the examination is necessary and issue a written notice of that decision to the senior next of kin. If the postmortem is deemed necessary, the senior next of kin is afforded 48 hours in which to appeal the decision to the Supreme Court.

The role of the forensic pathologist is to perform postmortem examinations for reportable deaths as ordered by the coroner and to give their opinion as to the medical cause of death. As coroners are judicial officers with no formal medical training, they rely heavily on the forensic pathologist to supply them with relevant, objective, and understandable medical information that will assist them in their investigations (1, 21, 23). What constitutes a postmortem examination is not defined, but some coronial acts allow this to be directed. For example, the Coroners Act 2009 [NSW] indicates the pathologist must use the least invasive procedures that are appropriate in the circumstances to ascertain the cause of death (14). In some instances, this may limit the postmortem to an external examination, radiological examination, and/or partial postmortem examination. In Queensland, the coroner may order a partial postmortem examination that is limited to a particular body cavity such as the head only (8). In most jurisdictions, a provisional cause of death is issued following completion of the postmortem examination. This enables the coroner to use these early, objective findings to guide further investigations. The coroners are then responsible for the issuance of a death certificate at the closure of their investigations. However, in Queensland, it is the forensic pathologist who issues the death certificate either directly after the postmortem examination or at a later stage when relevant results and ancillary information are available. In all jurisdictions, a final postmortem report is produced for the coroner, often several months after the death, when all of the forensic pathologist's investigations are complete. The conclusion of the report is written using lay terminology with explanations to enable it to be understood by those with a nonmedical background.

Forensic pathologists in Australia are medical specialists trained and accredited by the Royal College of Pathologists of Australasia (RCPA) (24). Registrar trainees can register with the college after obtaining a medical degree and completing one or more years of clinical work within the hospital system. Specialist training requires a minimum of five years working under supervision within laboratories and mortuaries. Some of this time must be spent learning anatomical (surgical) pathology. There is a series of examinations held in the third and fifth years of training, which must be passed prior to being accepted as a Fellow of the College. Forensic pathologists are employed by each of the state and territory governments usually under the Department of Health, but sometimes under the Attorney General's Department of Justice. In major cities, forensic pathologists often work in dedicated standalone forensic centers. However, in smaller cities and regional centers, they may work out of the district hospital mortuary.

Determination of Manner of Death

The coroner is able to engage all manner of assistance in investigating a death in order to serve the public interest (1, 2). From the outset, the coroner has access to the police report, and early on they will also have information from the postmortem examination followed by a final report. However, additional input sought by the coroner is wide-ranging and very much dependent on the case at hand. For example, in a hospital death, this may include medical charts, operative notes, interviews with nursing staff and doctors, and opinions from other medical specialists; whilst in a building site death, this may include architects, engineers, steel manufacturers, and lay witnesses. The legislated scope of the coroner's power is limited only by the public interest and when establishing the circumstances of death the coroner must investigate to a civil standard of proof, which is the balance of probabilities (1, 2, 25).

Determination of manner of death into ascribed, clearly defined categories, as is the practice within the medical examiner investigation system, is not formally a part of coronial investigation in Australia (25, 26). As described above, it is part of the coroner's role to determine, “What caused a person to die” (the medical cause of death) and enter this onto the death certificate. It is also part of their investigations to determine “How the person died” (the circumstances surrounding the death). In conducting these investigations, the purpose is to clarify the circumstances of a death in order to serve the public interest. This finding often accounts for the bulk of the coroner's investigative work and the facts are presented and explained extensively throughout their written report. Formal findings are often summarized in the conclusion and the circumstances of death presented as a narrative that strives to indicate whether a death was by natural or external (unnatural) means, and in the case of external findings, to discuss the intent and external factors leading to death. If they are not able to clarify the factors that led to the medical cause of death, then the reasons for this are explained. Hence, the circumstances of death are not presented in categories of manner and as such, manner of death is not included on the death certificate in Australia.

In some cases it may be necessary for the coroner to hold an inquest. For example, in Queensland, an inquest MUST be held if:

the person died in custody

the death occurred while a person was in care and there are issues about the care that was provided

the death occurred as a result of police operations (unless the coroner believes that an inquest is not required)

the attorney-general directs that an inquest is to be held

the state coroner orders that an inquest be held

the district court upholds an appeal against a coroner's decision not to hold an inquest (8, 27).

Coroners may also decide to hold an inquest if they consider that it is in the public interest.

The Coroner's Findings

At the conclusion of an inquest, legislation allows the coroner to make comments and recommendations arising from the case relating to wider issues in the community. Of note, the role of the coroner is inquisitorial, not adversarial in nature (1, 2, 23). The onus is to determine the circumstances of death on “balance of probabilities” and not to find guilt. The purpose is to make comment relevant to public health or safety, the administration of justice, and ways to prevent deaths from happening in similar circumstances in the future (28, 29). If, at the conclusion of the investigation, a coroner reasonably suspects a person has committed an offense, he/she must forward information to the Director of Public Prosecutions, the police, the relevant government department, and/or the relevant disciplinary body for a person's profession or trade (8). Importantly, any statement that a person is guilty of an offense or civilly liable must not be included in the findings.

At the conclusion of the investigation, the coroner's clerk notifies the relevant State or Territory Registry of Births, Deaths and Marriages, the police service, the family, and the State Coroner (if applicable within that jurisdiction) that the investigation has concluded. Other relevant agencies are notified for specific types of deaths. For example, in a reportable death that occurred in hospital, notification would be forwarded to the relevant health facility manager, patient safety and quality improvement service, the Office of the Health Ombudsmen, and/or the Australian Health Practitioner Regulation Agency (AHPRA). In these circumstances, the forensic pathologist's autopsy report may also be used for internal review at morbidity and mortality meetings and/or hospital audit.

The National Coronial Information System

Also at the conclusion of a coronial investigation, finalized information may be loaded into the National Coronial Information System (NCIS) (2, 23, 29). The NCIS is an Australasian database of coronial findings established in 2000 (30, 31). It was the first of its kind to be developed in the world and is an invaluable tool for collating information from death investigations around Australia and in New Zealand. Although this is a database and not a formal part of the coronial system, data are loaded onto the system by coronial clerks throughout the coronial investigation. The information entered includes demographics, cause of death details, incident circumstances and reports (i.e., coroners findings, initial police reports, postmortem reports, supporting forensic medical reports and other specialist reports commissioned by the coroner) (23, 29).

The database uses the internationally standardized coding system of the World Health Organization, International Classification of Disease (ICD-10) (32), to enter cause of death information onto the system allowing it to be readily searchable (29). The medical cause of death is entered, followed by the manner as natural, external (unnatural) or unknown. For external causes of death, intent is assigned using ICD-10 coding as unintentional injury, suicide, assault, legal intervention, operations of war, complication of medical or surgical care, other, undetermined, still enquiring or unlikely to be known (23). In this way, there is translation of the information on circumstances of death contained in the coroner's narrative into an ascribed standardized category of manner and intent. The NCIS is becoming an invaluable tool to facilitate public health knowledge and research, hence strengthening the coroner's role (2, 23, 29, 30).

Conclusion

Over time, there has been gradual maturation of the role of the coroner in Australia dating back to the introduction of the Coroners Act 1887 [UK] and continuing with the staggered introduction of individual state and territory legislation. This has concreted the role of the modern coroner as a public health official acting in the public interest. It is through their investigation of reportable deaths that they are able to make observations and recommendations about the cause and circumstances of death to assist in the creation and introduction of new public policies with the view of preventing similar deaths in the future. In recent years, this role has been greatly enhanced by the establishment of the NCIS, which has created a searchable database of collated information in order to identify trends and anomalies as they occur. So, although manner of death is not included on the death certificate and is not determined in the same fashion as in the United States medicolegal death investigation systems, it is a major part of the coroner's role to determine the circumstances of death and the external factors that led to the medical cause of death that is presented as a narrative in their findings.

Footnotes

The authors have indicated that they do not have financial relationships to disclose that are relevant to this manuscript

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