Chapter 5
An online process for certifying cause of death

Triggers for referral to the coroner

5.17In cases of sudden death, it will usually be obvious that the death must be referred to the coroner if it is the result of an accident or violence, suspected suicide or where the death occurred in official custody or care.43 In most of those cases, the Police will refer the death directly to the coroner.
5.18However, the majority of deaths occur after an illness or when the deceased person is elderly. In those cases, the doctor has a legal decision to make that will determine whether or not the death must be referred to the coroner. In most deaths after illness, if the doctor is not satisfied that the death was a natural consequence of illness, it must be referred to the coroner. However, it must also be referred to the coroner if it occurs:44
5.19Amendments to section 13 of the Coroners Act 2006 are currently proposed in the Coroners Amendment Bill.45 Those amendments will clarify that a death during or as a result of a medical procedure or anaesthetic must be reported to the coroner only if the death was not expected.

5.20Currently, both the Cremation Certificate and the Record of Death require doctors to answer questions designed to help them determine whether a death should be referred to the coroner. A number of submitters said that these types of questions should be asked in relation to all deaths. We agree with that suggestion. Whether the body is cremated or buried, there is a strong argument that the cause of death should be properly ascertained before the body is disposed of.

5.21Therefore, we consider that the online death certification process should ask questions of the certifying doctor, in respect of every death, that are designed to help the doctor determine whether the death should be referred to the coroner.

43Coroners Act, s 13.
44Section 13(1)(c) and (d).
45Coroners Amendment Bill 2014 (239-1).