Coronial process

The Coroners Act 2003 requires that a person immediately after becoming aware of a death that is, or may be, a reportable death, must notify the State Coroner or SA Police. This legislation provides the State Coroner with the authority to hold an Inquest into an untimely or unexpected death.

  • An Inquest held by the Coroner may involve investigation that leads to the release of a Finding of Inquest
  • The Coroner’s Office provides the Finding of Inquest directly to the relevant government agency.
  • Finding of Inquests that are directed at SA Health are received by SA Health’s Legal and Legislative Policy Unit who disseminate them internally to the relevant departments.
  • The Coroner’s Finding of Inquests are also publicly available on the State Coroner’s website.
  •  Some Finding of Inquests may include recommendations that aim to reduce the risk of a similar event re-occurring.
  • The Department of Health and Wellbeing Safety and Quality Unit is responsible for preparing a response to those recommendations directed at SA Health, on the Minister’s behalf.
  • 25.(5) of the Coroners Act 2003 refers to a legal requirement for the Minister of Health and Wellbeing to provide a report to the Coroner and to Parliament in response to any recommendations that are directed at SA Health, The Act states.
  • 25.(5) Each relevant Minister must, within 8 sitting days of the expiration of 6 months after receipt of a copy of a recommendation resulting from an inquest

(a) cause a report to be laid before each House of Parliament

(i) giving details of any action taken or proposed to be taken in consequence of the recommendation; or

(ii) if no action has been taken or is proposed to be taken—giving reasons for not taking action or proposing to take action; and

(b) forward a copy of the report to the State Coroner.

  • If recommendations from the Finding of Inquest are directed at SA Health, a response from the Minister for Health must be provided to the Coroner within 6 months of the Inquest Finding being handed down (the release date), and then to Parliament within 8 sitting days (Parliament sitting days).
  • If the Coroner makes no recommendations, a briefing to the Minister is required and the Coronial file is then closed.

State Coroner’s Office

SA Health staff who need to contact the State Coroner’s Office in relation to a reportable death must ring the State Coroner’s office on (08) 8204 0600.

Policy

SA Health has developed the Coronial Process and Coroners Act 2003 Policy Directive (PDF 208KB) to provide SA Health employees and other organisations contracted to provide a health service with a better understanding of the Coroners Act 2003, and to give clear direction and guidance regarding their obligations. 

Contact

For further information and assistance, or to provide feedback to enable continuous improvement, email:  Health.DHWClinicalGovernanceEnquiries@sa.gov.au

Reportable deaths

State Coroner Office
Phone: (08) 8204 0600