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

Uncertainty about which deaths are reportable is complicated by jurisdictional differences

In this issue of the Journal, Neate and colleagues review 320 deaths due to external causes in Victoria in the 2010–11 financial year that should have been reported to the coroner by doctors, but were not.1 Based on the causes of death reported on the death certificates, the Registry of Births, Deaths and Marriages referred the cases to the coroner for investigation. These deaths represent 6.6% of the total 4857 deaths reported to the coroner that year.2 Of these unreported deaths, 307 (96%) were the result of injuries from falls, 80% of the deceased were aged 80 years or older, and 68% of them were in hospital at the time of death. In 309 cases (97%), the cause of death was changed based on forensic pathology advice. One case went to an inquest. The fact that the external cause of the death — overwhelmingly fracture of the hip or pelvis, or head injury — was evident on the death certificate would seem to indicate a misunderstanding about the reportability of the deaths, rather than a conscious attempt to subvert the system.