Impact of coronial investigations on manner and cause of death determinations in Australia, 2000–2007

Coroners’ courts in the United Kingdom and countries of the British Commonwealth, including Australia, Canada, and New Zealand, have much in common.1,2 Fatalities that occur in designated circumstances must be reported to the coroner, who investigates the manner, cause and circumstances of those deaths. The process is judicial, although it relies heavily on medical evidence. Unlike most other jurisdictions in the justice systems of these countries, the approach is inquisitorial, not adversarial. A coroner’s investigation may include an inquest, but most do not.2

In Australia, coroners’ courts are state-based jurisdictions. The nature of reportable deaths differs slightly across the six states and two territories. In general, unexpected, unnatural or violent deaths must be reported, including those related to an injury or accident. Deaths occurring while a person is held in a state facility must be reported, as must certain operative deaths and most deaths in which the identity of the deceased or the cause of death is unknown.

The performance of clinical services serving coroners’ courts, particularly pathology and toxicology, has been well studied, as have death certification and reporting behaviour of doctors.3-5 By contrast, there has been very limited empirical investigation of how coroners themselves function and make decisions.2,6,7 This knowledge gap is surprising in Australia, given the remarkably high public profile of coronial work here.8

A new national repository of coronial cases — to our knowledge, the first database of its kind anywhere — has created opportunities for such research in Australia.9 In our study, we use this database to investigate how frequently, and for what types of deaths, the understanding of the manner and cause of death changes between the time a report arrives at a coroner’s court and the completion of the coroner’s investigation. We hypothesised that it would be quite rare for the coronial process to introduce substantial change to what was presumed at the time of notification, on the basis of police reports, initial medical opinion, and other circumstantial information. Nonetheless, better recognition of the circumstances in which coronial investigations substantively alter the perceived manner and cause of death may help focus the attention of coroners, pathologists and others on cases with misleading first appearances. More generally, this information should highlight the types of cases in which the coronial process serves a particularly important function.

Our study attempted to get inside the “black box” of the coronial process in Australia by examining its impact on cause of death determinations. The coroner’s role in establishing cause of death is especially valuable for fatalities in which the fundamental cause is obscure, or first impressions are misleading. We found that in about 1 in 20 deaths reported to coroners in Australia between 2000 and 2007 there was a change in the basic understanding of the manner of death or type of external cause during the course of the coronial investigation.

Few empirical studies in Australia14,15 or elsewhere6,7 have investigated the processes of coronial decision making. Explanations for this paucity of research include the absence of a public health tradition within coronership, data constraints (at least before the establishment of the NCIS), and, perhaps most importantly, a general disinterest among courts and legal scholars in tracking and analysing cases at the “population” level.

The task of establishing cause of death has been regarded as an important public function in civil society since the middle ages.16 Today, many considerations — public health, social justice, the integrity of vital statistics, and concern for families and friends of the deceased — dictate that getting cause-of-death determinations right is crucial in a well functioning society. But it is a formidable challenge. Coroners have limited manpower and resources and most deal with large caseloads — Australia-wide, about 18 000 deaths per annum are reported to coroners. Therefore, high performance in accurately identifying causes of death requires prudent allocation of available time and directing effort towards deaths requiring close investigation. Findings from studies like this one may improve coroners’ ability to identify such cases.

Our study has several limitations. First, the manner and intent categories that form the basis of our transition measurements are broad. More detailed information on the nature, cause and circumstances of death may emerge during the course of a coronial investigation, and have substantial value to families and society.

Second, NCIS coding instructions stipulate that coronial clerks should classify the causes as they are understood “at the time of notification to the coroner” and this “should not be updated throughout or at the completion of the coronial investigation”.10 To the extent that this instruction was breached, and late coding or revisions occurred that were not caught by the NCIS’s quality assurance procedures, the presumed and final causes will more closely resemble one another. The effect on our estimates of the frequency of transitions from one cause classification to another would be to render them an underestimate; the effect on findings related to the mix of cases in which transitions occur is unknown.

Finally, cases notified up to the end of 2007 were eligible for our study sample provided they were closed. At the date we extracted the sample from the NCIS, 93% of all NCIS cases notified through to 31 December 2007 had closed, but only 84% of notifications in 2007 had closed, creating a potential source of bias. We re-ran the analyses restricting the case sample to those notified through to the end of 2005, which meant 95% of 2005 notifications and 95% of 2000–2005 notifications had closed by the date of extraction. This reduced the sample size by 30%, but the rates and proportions forming our main study findings were essentially unchanged.

In summary, findings from this study indicate that coronial investigations in Australia change basic presumptions about how deaths occur in only a small minority of cases. Those changes, when they occur, may be very important to the families involved. At a whole-of-caseload level, however, our findings raise questions about whether the role of coroners’ courts can be justified solely or principally by focusing on their function as establishers of cause of death, traditionally the coroner’s core activity.

In the past few years, an important period of coronial law reform has begun globally.3,17,18 The most significant reforms involve elevating the importance of the non-traditional functions of coroners — for example, helping families to understand and cope with the death of loved ones, and formulating public-health recommendations and monitoring their implementation. These functions may eventually grow to eclipse death certification as the coroner’s chief contribution to society.

2 Comparison of manner of death presumed at notification with manner of death established at closure of coronial investigation in cases in which a presumption was made (n = 120 452)*

Presumed manner of death	Number (%)	Coronial investigation		Established manner of death	No. (% of category total)
Natural	75 801 (62.9%)			Natural	73 521 (97.0%)
				External	1 891 (2.5%)
				Unknown	389 (0.5%)
External	41 286 (34.3%)			External	40 314 (97.6%)
				Natural	842 (2.0%)
				Unknown	130 (0.3%)
Unlikely to be known	3 365 (2.8%)			Natural	1 672 (49.7%)
				External	698 (20.7%)
				Unknown	995 (29.6%)
* In 2042 of the total of 122 494 cases, a presumption was not made. These cases were designated: “still enquiring” (1 977 [1.6%]); “body not recovered” (59 [< 0.1%]); and “missing” (6 [< 0.1%]).

3 Deaths due to external causes among those presumed at notification to be due to natural causes (left side), and deaths due to natural causes among those presumed at notification to be due to external causes (right side)*

Natural → external (n = 1891)	No. (%)		External → natural (n = 842)	No. (%)
Unintentional injury	1340 (70.9%)	Cardiovascular	551 (65.4%)
Fall	442 (23.4%)	Ischaemic heart disease	264 (31.4%)
Poisoning by pharmaceutical(s)	264 (14.0%)	Congestive heart failure, arrhythmias	103 (12.2%)
Alcohol toxicity	152 (8.0%)	Cerebrovascular disease	89 (10.6%)
Asphyxiation on food or vomit	136 (7.2%)	Other haemorrhage, vessel dysfunction	39 (4.6%)
Transport accident	85 (4.5%)	Inflammatory heart disease	20 (2.4%)
Asbestos exposure	62 (3.3%)	Other	36 (4.3%)
Adverse event due to medical care	312 (16.5%)	Infection	124 (14.7%)
Complications of surgery	154 (8.1%)	Pneumonia	93 (11.0%)
Complications of medical procedures	74 (3.9%)	Sepsis	24 (2.9%)
Adverse drug event	47 (2.5%)	Other	7 (0.8%)
Other adverse events	37 (2.0%)	Gastrointestinal	32 (3.8%)
Suicide	135 (7.1%)	Liver failure	18 (2.1%)
Poisoning by pharmaceutical(s)	91 (4.8%)	Bowel obstruction, necrosis	7 (0.8%)
Multiple substances	51 (2.7%)	Other	7 (0.8%)
Antidepressants	15 (0.8%)	Respiratory disease	34 (4.0%)
Asphyxia by hanging	14 (0.7%)	Cancer	18 (2.1%)
Poisoning by other means	15 (0.8%)	Other	67 (8.0%)
Unknown intentionality	93 (4.9%)	Indeterminate	16 (1.9%)
Poisoning by pharmaceutical(s)	72 (3.8%)
* All categories in the natural → external causes group are shown except “Assault” (7) and “Other” (4), and leading subcategories are shown. All categories and subcategories in the external → natural causes group are shown.