Doctors, death certificates and reporting to coroners — room for improvement

In reply: We note MacCallum and Anazodo’s concerns about our recommendations1 leading to an unmanageable increase in reporting of deaths to the coroner, despite their acknowledgement of the legal and public health implications of non-reporting of reportable deaths.

The Coroners Court of Victoria (CCOV) has been supported in the development of an integrated statewide system of death investigation aimed at improving timeliness. Important changes include an emphasis on preliminary investigations and verbal communication of a cause of death to clinicians by forensic pathologists, in recognition of the importance of timely, accurate feedback to treating clinicians. The CCOV also has a Coroners Prevention Unit, staffed by clinicians and case investigators, to provide expertise and triage recently reported health care-related deaths so that important health and medical system investigations can be prioritised.

We would suggest that other jurisdictions consider early involvement of clinicians in their coronial review processes to help facilitate more timely resolution of these important matters for both treating doctors and families and to ensure that public health outcomes are prioritised.