Coronial Study - The Coronial System
The coronial system
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The history and changing nature of the coronial system was extensively
explored at a conference held in November 1991 at the Australian
National University.(1) The role of the coroner has long been “to
determine the identity of the deceased, when and where they died,
how their demise came about, what the cause of death was and whether
anyone contributed to their departure from this mortal coil.”(2)
Not all deaths come under a coroner's attention. The coroner
specifically investigates deaths that involve violence, unnatural
deaths or sudden deaths of which the cause was not known and those
which occur in prison.
In addition to these basic functions coroners have, from time
to time, made comments and recommendations “designed to prevent
the recurrence of fatalities similar to that in respect of which
an inquest has been held.”(3) This function has grown and changes
to the Coroner’s Act in several Australian jurisdictions
since 1975 specifically make provision for the coroner to make
recommendations “on any matter connected with a death which
the coroner investigated, including public health or safety or
the administration of justice.”(4)
The basic functions of the coroner vary only slightly from State
to State. One important difference is the role of the coroner
when criminal charges relating to the death are to be laid. In
some States the coroner's case proceeds to a finding, albeit that
this is delayed until the criminal case is heard. In others, the
criminal process takes precedence and the coronial process is
terminated.
The organisation of the coroner's administrative system, however,
varies more. In SA, Vic., NSW and the NT a State coroner's system
has been introduced. This places the responsibility for the coronial
system to rest with one coroner, who coordinates and oversees
the activities of a number of local coroners. In the ACT, Tas.,
Qld and WA a move to a State coroner's system is mooted and draft
legislation has been, or is in the process of being introduced.
This arrangement has considerable significance. Under a State
coroner's system, it can be expected that centralised information
systems will be more easily managed; that investigation practices
and the nature of findings will be more consistent; and opportunities
for gaining an overview of all cases in the jurisdiction, increased.
Investigative practices also vary from State to State. In all
States the coroner's clerk is a key organiser of the investigative
resources on behalf of the coroner. Australia has a population
concentrated in a number of dense urban areas with a small proportion
of people living in varying levels of density across a vast continent.
Investigation systems reflect this. In small jurisdictions such
as the ACT and Tas., police investigation of coronial matters
are limited to specialist police officers. In the NT, despite
its vast area, the small number of coronial deaths also make it
possible to undertake police investigations with a small specialist
force. In States with larger populations (and so more deaths
requiring the attention of the coroner) and where vast areas can
be encountered, coronial investigations are conducted by numerous
police officers under the direction of many coroners. In some
States, magistrates act as local coroners. Forensic pathology
and toxicology services also vary from centrally based specialists
to decentralised services based on professionals employed by health
services mainly for other duties.
While coroners have great similarities in function, and there
is general agreement among coroners about their role, there are
considerable differences in way the work is organised which require
attention in the design of a national coronial information system
(NCIS). Individual coroners retain a high level of autonomy.
Examination of findings and processes reveals considerable differences
in investigative procedures, the information gathered and the
nature and level of detail of findings.
The key functions of the coroner require more detailed examination.
The coroner is primarily an investigator. The traditional role
of the coroner has been as a case investigator but the expanding
role described above has required the coroner to move into the
role of investigator of classes of events and of patterns in causes
and effects. The coroner's role in managing investigations requires
the assistance of others with the requisite skills and resources.
The backbone of this investigative process is the police officer
aided by an appropriate range of experts. It is, however, primarily
the coroner who determines how a case or group of cases will be
investigated, what evidence is obtained and what is determined
to be relevant. The Coroner's Act determines the powers of the
coroner to gather evidence. The coroner determines the need for
an autopsy, the relevance of toxicological studies, the range
of information about circumstances leading to death and the evidence
necessary to identify the deceased. The legislation also gives
the coroner considerable latitude to determine the level of inquiry
and whether an inquest is necessary or can be dispensed with.
The choices made by the coroner are determined by the merits of
each case and the preliminary information provided soon after
the discovery of the body. The information which is gathered
and the way it is recorded is largely determined by the individual
coroner operating within the provisions of the relevant Coroner's
Act. The extent of information required to make a determination
on a particular case may be less than that required to fulfil
the public interest role. Given that a strong emphasis of this
broader role has only developed in the last ten years or so, it
is not surprising that there have been considerable differences
between coroners about what information is relevant, how the information
should be gathered and defined, and how it should be stored and
indexed. This has resulted in different practices and subsequent
difficulties in exchanging and comparing information.
The coroner's preventive role goes beyond the prevention of death.
Often, a small number of deaths is just the tip of the iceberg
of a broader injury problem. The coroner has the ability to investigate
the deaths, identify other injuries and make recommendations which
not only prevent deaths but many non-fatal injuries as well.
The modernisation of the coroner’s role has therefore created
an imperative for changes to the scope and definition of information
and the development of different retrieval and research approaches.
The forensic pathologist contributes to the coroner's investigation
by providing information which can be used to determine the cause
of death. The use of the phrase ‘cause of death’ can
result in some confusion. In public health terms, the cause of
death may well be a motor vehicle crash or drowning, but the pathologist
is primarily interested in the patho-physiological cause of death.
Australia operates a system which has both full-time specialist
forensic pathologists and those who are part-time in this role.
State Forensic Units have been established in Vic., NSW, SA QLD
and WA. There has been considerable debate about the role of
the forensic pathologist, the relationship to the police system
and the degree of specialisation required. It is not the role
of this needs study to enter into this debate, but to recognise
that information about cause of death varies from case to case
depending on where the death occurs and who conducts the post
mortem, and that the information needs of forensic pathologists
will differ according to the support structure in which they work.
A good information system will provide access to information about
approaches of forensic pathologists across the nation.
The coronial investigation starts when a notifiable death occurs.
There are minor differences in the wording of definitions of a
notifiable death from State to State, but essentially the same
types of death are included in all jurisdictions. Notifiable deaths
consist mainly of violent deaths both accidental and intentional,
sudden deaths where the cause is unknown or the death unexpected,
and deaths which occur in prisons or residential institutions.
Police attend the death scene and gather preliminary evidence.
The coroner then determines the level of detail of the investigation
according to this preliminary assessment and other observations
made if the coroner attends the death scene. Decisions are then
made about what evidence is to be collected, whether a post mortem
is to be completed, or toxicological examinations done. The decision
about whether the case will proceed to an inquest is based on
this information and the requirements of the State Coroner's Act.
This process varies considerably from coroner to coroner and from
jurisdiction to jurisdiction. Current information systems do
not permit the patterns of investigations, or even the use of
post mortems of individual jurisdictions to be described in detail.
The level of detail, and the scope of information gathered, varies
greatly. Some of these variations are quite appropriately related
to the type of case. A sudden death from a myocardial infarction
attracts a totally different response than from a suspected homicide,
and a road crash often results in a full mechanical analysis,
sometimes referred to as a vehicle autopsy. There are, however,
variations from jurisdiction to jurisdiction and coroner to coroner
which result in potentially similar cases being investigated in
a different manner. While this may well be justifiable on a case
by case basis, it presents difficulties for an information system
which attempts to aggregate information across cases. An information
system must be able to retrieve relevant cases consistently, without
missing cases or including cases which are not relevant. Missing
information, or the use of different terminology by different
users, can severely affect the reliability and validity of the
retrieved information. This, to some extent, can be offset by
sophisticated text retrieval systems, but even these rely on all
appropriate search terms being defined and sufficient selectivity
to exclude irrelevant cases.
There are so many investigators and information providers involved
in coronial investigations that there is a need to address the
question of the standardisation of what is covered in each type
of investigation and how this is recorded.
The coroner’s findings vary from brief descriptions about
the place of death, the identity of the deceased and the cause
of death, covering less than half a page on a standard form, through
to detailed descriptions of the circumstances leading to death,
the standard information described above and detailed riders or
recommendations concerning what could be done to prevent similar
deaths and injuries. The variety of cases makes this entirely
appropriate, but examination of the processes in each jurisdiction
shows that the scope of coverage and level of detail in the finding
is not consistent across similar cases. The variation is most
marked between jurisdictions, but also occurs between coroners
in the same jurisdiction and even for the same coroner for different
cases.
The coroner's finding is very important to other coroners who
are investigating a similar death and to researchers who wish
to aggregate information in order to reveal patterns of contributing
factors associated with deaths. A national information system
would benefit from a more uniform approach to presenting findings.
This is likely to occur naturally if the system allows rapid
interchange of information, but will also require coordinated
effort by coroners to develop a system of reporting which is consistent
between individual coroners but has sufficient variability to
cater for the wide range of cases encountered.
The role of an information system is to permit exchange of information
between coroners and interested parties with a view to the efficient
identification of issues requiring attention. Coroners' investigations
provide a rich source of information capable of forming a basis
for sound preventive activity. An information system must be able
to assist coroners and researchers to identify clusters of events
which may be fruitful areas for prevention. Currently this process
is severely limited because coroners' records are based on manual
filing systems and lack indexes to identify or retrieve clusters
of like cases. A new information system is required which permits
a wide range of disciplines to assist in the process of issue
identification and problem analysis according to their own research
paradigms.
(1) Selby H (Ed.), The Aftermath of Death, Leichhardt Federation
Press, 1992.
(2) Freckleton I, Expert Proof in the Coroner’s Jurisdiction,
in Selby H (Ed.), The Aftermath of Death, Leichhardt Federation
Press, 1992, p39.
(3) Waller K, The modern approach to coronial hearings in Australia,
in Selby H (Ed.), The Aftermath of Death, Leichhardt Federation
Press, 1992, p3.
(4) Victorian Coroner's Act, (s(21(2))).
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