Last updated 20 January 2022

An independent forensic medicine doctor from the Queensland Health Clinical Forensic Medicine Unit (CFMU) will undertake an initial investigation by reviewing the deceased’s medical records and seeking further information from members of the treating team. The CFMU doctor will then prepare a written summary of their review with their opinion about the deceased’s health care management, flagging any concerns they may have.

The written summary by the CFMU doctor can help reassure families that concerns have been considered and informed by independent clinical opinion. If the CFMU doctor does not have any concerns with the deceased’s health-care management, the coroner should authorise the death certificate and advise that no further investigation is required. If the CFMU doctor has concerns about the treatment, the coroner will not issue the death certificate and will advise the further investigations required. These further investigations may involve obtaining witness statements, medical records, Medicare records, a root cause analysis and hospital policies.

The outcome of the CFMU review will be provided to the coroner in a formal report, which, at the appropriate time, may be released to the family and the treating practitioners.

Case Study: Lilli Sweet  

On 25 August 2013, Lilli Sweet (6 years old) presented to her GP with vomiting, diarrhoea and a headache. Given Lilli’s underlying medical condition, which made her particularly susceptible to infection, her GP referred her onto the Nambour Hospital Emergency Department for blood tests. Despite her symptoms continuing, the blood tests were not taken until that evening. The results indicated that Lilli’s white blood count was elevated, suggesting serious sepsis. It was not until the next morning when Lilli rapidly deteriorated, that intravenous antibiotics were commenced and she was transferred to the Royal Children’s Hospital in Brisbane.

The next day, she was declared dead from meningitis. The coroner found that medical staff at the hospital missed opportunities to act earlier and prevent Lilli’s death (see Inquest into the death of Lilli Sweet (2016) 2013/3454).

The coroner also noted that the Sunshine Coast Hospital and Health Service (HHS) and Queensland Health had already implemented a number of recommendations from the root cause analysis into Lilli’s death, including establishing clear processes, procedures and systems for tracking diagnostic results to ensure they are received, reviewed and actioned. As a result of the significant changes made by the HHS and Queensland Health, the coroner did not propose any further recommendations, highlighting that HHSs can instigate reform prior to specific recommendations being handed down by the coroner.