Last updated 20 January 2022

The next step after a death is reported to the coroner is working out why the death occurred.  That will often involve the use of medical opinion and/or forensic testing.

Preliminary examinations

Once police submit a Form 1 to the Coroners Court, the coroner’s investigation begins with a range of preliminary procedures performed by forensic pathologists. The scope of these preliminary examinations will depend on the circumstances of each death, and may include:

  • visual examination of the body, including dental examinations
  • post-mortem imaging of the body, including CT scans, MRI scans and x-rays
  • taking and testing blood, urine, saliva, swabs and other samples
  • fingerprinting
  • collating information about the deceased’s medical history.

The purpose of these preliminary examinations is to help inform the coroner about whether the death is a reportable death, and whether further coronial investigations, such as an autopsy, are required. In 40% of cases where a death is reported because a cause-of-death certificate is not issued, no further coronial investigations are required because a forensic pathologist is able to issue the certificate outlining the cause of death.

In practice, the taking of samples and testing is time critical and needs to occur within 6 to 12 hours of a person’s death. In urgent cases, a coroner or coronial registrar may allow a pathologist to carry out preliminary examinations after the death is reported to the coroner in writing (e.g. by email), without the Form 1 being lodged first.

Considerations during preliminary examinations

Any concerns that you have about that the preliminary examinations (e.g. a sampling process being invasive) should be outlined in the Form 1. The examiner must take these concerns into account and must also consider the cultural traditions and spiritual beliefs of the deceased person and their family, when determining the types of samples that should be taken (s 11AA(5) Coroners Act 2003 (Qld) (Coroners Act)).

Written preliminary report

A written preliminary examination report must be prepared and provided to the coroner as soon as practicable after the preliminary examination is completed (s 11AA(6) Coroners Act).  This report is confidential and cannot be given to anyone other than a coroner or the Coroners Court. The report will contain:

  • information considered by the examiner including the deceased’s medical and circumstantial history
  • results of any imaging, sampling, testing and other procedures performed as part of the preliminary examination
  • a view about the likely medical cause of the person’s death or a recommendation as to the type of autopsy that is likely to establish the cause of death.

In circumstances where there are questions as to whether a cause-of-death certificate can be issued, or what type of autopsy should be ordered, a coroner will consider the preliminary examination report before ordering an autopsy.

If it is clear from the outset that preliminary examinations will not help the coroner in determining whether the death is a reportable death, or the type of autopsy that would identify the cause of death, a preliminary examination report will not be issued. Instead, the results of the preliminary examinations will form a part of the autopsy report.

Finalising a matter following preliminary examinations 

If a death has been reported because a cause-of-death certificate had not been issued, and the cause of death can be established from preliminary investigations, a coronial nurse or coronial counsellor will consult the deceased’s family about any concerns they may have about the circumstances of the death. If no concerns are raised by the family, the coroner may decide to discontinue the coronial investigation, not order an autopsy and issue a cause-of-death certificate, which will then be placed on the coronial file in the Coroners Court registry.

The decision not to order a coronial autopsy puts an end to the coronial process, and must not be made unless the coroner considers that the death is not a reportable death or that no further coronial investigation is needed. The file will then be closed with a note about the decision made that the death was not reportable. The family will then be informed that they can arrange for release of the body and arrange the funeral.