Usually a police officer or doctor will notify the State Coroner of any death that may be a reportable death.

A death must be reported to the State Coroner where it has occurred:

  • unexpectedly, unusually or by a violent, unnatural or unknown cause
  • on a flight or voyage to South Australia
  • while in custody
  • during, as a result or within 24 hours of certain surgical or invasive medical procedures, including the giving of an anaesthetic for the purpose of performing the procedure
  • within 24 hours of being discharged from a hospital or having sought emergency treatment at a hospital
  • while the deceased was a ‘protected’ person
  • while the deceased was under a custody or guardianship order under the Children and Young People (Safety) Act 2017
  • while the deceased was a patient in an approved treatment centre under the Mental Health Act 2009
  • while the deceased was a resident of a licensed supported residential facility under the Supported Residential Facilities Act 1992
  • while the deceased was in a hospital or other facility being treated for drug addiction
  • during, as a result or within 24 hours of medical treatment to which consent had been given under Part 5 of the Guardianship and Administration Act 1993
  • when a cause of death was not certified by a doctor.

Following a report of a death, the State Coroner must decide if it is necessary to hold an inquest to determine the cause and circumstances of the death.

This involves a process to identify the deceased.  Visual identification is usually done by someone who knew the deceased well.   Sometimes identification may need to be made through fingerprints, dental records, DNA testing or circumstantial evidence.

If the situation necessitates, a doctor or qualified paramedic will certify that death has occurred.

It may also be necessary for a post-mortem or autopsy to be performed to establish the specific medical cause of death.

The processes of identification and post mortem may mean that the release of the deceased to the family’s Funeral Director is delayed.

As part of the investigation the State Coroner may direct police assigned to his office to seek further information.  This does not mean that there is something suspicious or sinister about the death.   Statements can be taken from witnesses relating to the circumstances of the death and police can also provide statements detailing their investigation.   Reports can also be sought from experts in areas such as medicine, surgery, fire, air safety, road safety, work-place safety or engineering.

The following brochure is intended to provide timely information about the coronial system, why the State Coroner has become involved, and the processes which may be necessary to determine the cause of death. The brochure also outlines the rights of next of kin.

Coronial Process.pdfDownload