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CORONIAL FRAMEWORK 4

DCSI

CORONIAL GUIDELINES

AND

MANDATORY PROCEDURES

Document number For OIS use.Version 3.1Date of version September 2014Applies to All DCSI staffIssued by Financial ServicesDelegated authority Andrew Thompson,

Executive Director Financial Services

Procedure custodian Nancy Rogers, Director Business Affairs

Date Published For OIS use.Due for review June 2015Confidentiality For Office Use Only

FOUODCSI strategic objective

-- If relevant --

SA Strategic Plan -- If relevant --

Contents

1. Introduction

2. Background and context

3. Scope

4. Definitions

5. Reportable deaths

6. Police requests for information - provision of records and witness statements

7. Insurance

8. Communication with the Coroner’s Office

9. Inquests of interest to DCSI

10. DCSI employees giving evidence at an inquest - legal and media assistance

11. Coroner’s Court findings and recommendations

12. Reporting

Appendix 1 – DCSI roles & responsibilities

Appendix 2 – Guide to determining reportable deaths

For office use only3 | DCSI – DCSI Coronial Guidelines and Mandatory Procedures

1. Introduction

1.1 The Department for Communities and Social Inclusion (DCSI) Coronial Guidelines and Mandatory Procedures (the Guidelines and Procedures) provide guidance on how to manage and respond to a reportable death and comply with resulting responsibilities in the event of a Coronial investigation or inquest of interest to the department. These Guidelines and Procedures should be read in conjunction with the Coronial Policy.

Appendix 1 lists the DCSI roles and responsibilities for the Guidelines and Procedures.

2. Background and context

2.1 The role of the Coroner is to ensure the proper management of investigations and inquests into deaths, fires, accidents and the disappearance of missing persons.

2.2 Following the report of a death, the Coroner must decide if it is necessary to hold an inquest into the cause and circumstances of the death. As part of a Coronial investigation, DCSI staff may be approached for further information by police assigned to the Coroner’s Court.

2.3 If the Coroner believes that the cause or circumstances of a death are a matter of substantial public importance, if they relate to public health or safety, or in certain prescribed circumstances, an inquest may be held.

2.4 An inquest is a court hearing in which the Coroner gathers information to assist in determining the cause and circumstances of a death. If appropriate, the Court makes recommendations that may prevent similar deaths occurring in the future. Generally, inquests are open to the public and Coroner’s findings are available online.

2.5 An inquest is not classified as a trial as it is not the Court’s role to establish whether a crime has been committed or to find a person guilty of a crime.

2.6 These Coronial Guidelines and Mandatory Procedures support DCSI in complying with the Coroners Act 2003 and fulfilling the intent of the DCSI Coronial Policy.

3. Scope

3.1 These Guidelines and Procedures are intended to support all divisions with Coronial matters, from reporting a death to the Coroner, through to acting upon recommendations arising from an inquest.


4. Definitions

Coroner means the State Coroner, or a Deputy State Coroner, or any other Coroner appointed under Part 2 of the Coroners Act 2003.

Coronial matters of interest to DCSI includes but is not limited to reportable deaths; deaths in custody; deaths of clients, former clients and staff; deaths of people particularly vulnerable at the time of death (e.g., transient Aboriginal and Torres Strait Islander people; a person experiencing domestic violence or other form of abuse); and disappearances, fires and accidents.

DCSI Coronial Officer means the DCSI staff member located within Business Affairs, Financial Services Division, who is responsible for the monitoring of Coronial investigations and inquests of interest to DCSI and for assisting DCSI service divisions with compliance with this policy. Contact details are published on the intranet.

Death in Custody means the ‘death of a person where there is reason to believe that the death occurred, or the cause of death, or a possible cause of death, arose, or may have arisen, while the person –

(a) was being detained in any place within the State under any Act or law, including any Act or law providing for home detention (and, for the purposes of this paragraph, a detainee who is absent from the place of his or her detention but is in the custody of an escort will be regarded as being in detention, but not otherwise); or

(b) was in the process of being apprehended or was being held –

(i) at any place (whether within or outside the State) – by a person authorised to do so under any Act or law of the State; or

(ii) at any place within the State – by a person authorised to do so under the law of any other jurisdiction; or

(c) was evading apprehension by a person referred to in paragraph (b); or

(d) was escaping or attempting to escape from any place or person referred to in paragraph (a) or (b)’ (section 3, the Coroners Act 2003).

Delegate means a supervisor, manager or other senior DCSI staff member to whom responsibilities under the Coronial Policy and/or Coronial Guidelines and Mandatory Procedures have been delegated for operational reasons. A delegate must be in a position to report the death within 24 hours to the Coroner/SAPOL.

Divisional Coronial Liaison Officer means the DCSI staff member located in each division of DCSI responsible for supporting their division’s compliance with the Coronial Policy and Coronial Guidelines and Mandatory Procedures. Contact details are published on the intranet.

Funded organisations are organisations funded by DCSI that provide direct client services on DCSI’s behalf.

Minister means the Minister for Communities and Social Inclusion, Minister for Social Housing, Minister for Disabilities, Minister for Youth, Minister for Multicultural Affairs, Minister for Volunteers, Minister for the Status of Women or any other portfolio responsibility within DCSI.

Other Critical Incident means the disappearance of a person or fire or accident resulting to injury to person or property, as referred to in section 21 of the Coroners Act 2003.


Reportable death means ‘’...the State death…of a person –

(a) by unexpected, unnatural, unusual, violent or unknown cause; or

(b) on an aircraft during a flight, or on a vessel during a voyage; or

(c) in custody; or

(d) that occurs during or as a result, or within 24 hours, of-

(i) the carrying out of a surgical procedure or an invasive medical or diagnostic procedure; or

(ii) the administration of an anaesthetic for the purposes of carrying out such a procedure, not being a procedure specified by the regulations to be a procedure to which this paragraph does not apply;

(e) that occurs at a place other than a hospital but within 24 hours of -

(i) the person having been discharged from a hospital after being an inpatient of the hospital; or

(ii) the person having sought emergency treatment at a hospital; or

(f) where the person was, at the time of death-

(i) a protected person under the Aged and Infirm Persons’ Property Act 1940 or the Guardianship and Administration Act 1993; or

(ii) in the custody or under the guardianship of the Minister under the Children’s Protection Act 1993; or

(iii) a patient in an approved treatment centre under the Mental Health Act 1993; or

(iv) a resident of a licensed supported residential facility under the Supported Residential Facilities Act 1992; or

(v) accommodated in a hospital or other treatment facility for the purposes of being treated for drug addiction; or

(g) that occurs in the course or as a result, or within 24 hours, of the person receiving medical treatment to which consent has been given under Part 5 of the Guardianship and Administration Act 1993; or

(h) where no certificate as to the cause of death has been given to the Registrar of Births, Deaths and Marriages; or

(i) that occurs in circumstances prescribed by the regulations…’ (section 3, Coroners Act 2003).

5. Reportable deaths

5.1 On becoming aware of a death that is or may be a reportable death, a staff member or their delegate must immediately notify the State Coroner (8204 0618) if it is a death in custody, or SAPOL (131 444) if it is any other type of reportable death.

A staff member is not required to report a reportable death to the Coroner if they are aware, or otherwise believe with good reason, that the death has already been reported by someone else1. If in any doubt –

11 If the staff member or delegate suspects that the death has already been reported by another agency, for example SAPOL or SA Health, they should, at a minimum, seek verbal confirmation of this before deciding not to report.


either about whether the death is reportable or about whether it has already been reported - the staff member or their delegate must report the death.

Appendix 2 provides a checklist to help staff determine whether a death is a reportable death.

The maximum penalty for failing to notify the Coroner or SAPOL is $10,000 or 2 years’ imprisonment.

5.2 A staff member or their delegate, immediately upon becoming aware of a death that is or may be a reportable death, must advise their Manager/Team Leader/Supervisor of the incident either in person or by phone.

5.3 The Manager must immediately report the matter to his or her Director and/or Executive Director either in person or by phone followed by an email.

5.4 If, following advice from the responsible Director in consultation with the responsible Executive Director, the reportable death is also deemed a critical client incident, the Director must immediately follow the internal reporting, briefing and incident management requirements in accordance with the Department’s Managing Critical Client Incidents Policy and their divisional Managing Critical Client Incidents Guideline.

5.5 Staff who are informed by a funded organisation of the reportable death of a client must follow the same procedure, and immediately advise their Manager/Team Leader/Supervisor of the matter either in person or by phone.

5.6 Having reported the death by phone to the Coroner or SAPOL, the staff member or their delegate must report and record the matter on Riskman, as soon as practicable. For divisions that do not use Riskman for client incidents, staff must complete the DCSI Reporting a Death form.

5.7 In the event of a reportable death in a Disability Aged Care Facility (Highgate Park) staff must complete the State Coroner’s Court Death Report to the Coroner Aged Care Facility/Institution form. A copy of the form must be uploaded to Riskman or sent to the Divisional Coronial Liaison Officer.

5.8 The Divisional Coronial Liaison Officer must send electronically a copy of the completed Riskman report, DCSI Reporting a Death form or the Death Report to the Coroner Aged Care Facility/Institution form to the relevant Executive Director, the relevant Divisional Director, the Director, Legal Services Unit, DCSI Insurance Services and the DCSI Coronial Officer.

5.9 In addition to the above procedures, staff must follow any departmental, divisional and joint-agency guidelines, procedures or protocols for reporting incidents and deaths.

5.10 If the death is a death in custody, or a critical client incident, an urgent briefing from the Executive Director to the Chief Executive and Minister must be prepared. Copies of the briefing must be provided to the DCSI Coronial Officer, the relevant Divisional Coronial Liaison Officer and the Director, Legal Services Unit.

5.11 The DCSI Coronial Officer shall record the reportable death in the Coronial Matters Register. The divisional staff member, delegate or Divisional Coronial Liaison Officer shall also record the incident in any divisional Coronial database, according to divisional policies and procedures.


6. Police requests for information – provision of records and witness statements

Please note: Police may request records and statements from DCSI staff as part of a criminal investigation. Since all reportable deaths must be investigated by SAPOL and SAPOL will, upon the conclusion of any criminal proceedings, prepare a report for the Coroner about the particular aspects of the incident of interest to the Coroner, it may be that records and statements obtained by SAPOL as part of a criminal investigation inform a subsequent Coronial investigation and inquest.

6.1 RECORDS 6.1.1 Following a reportable death, staff may be approached by SAPOL to provide relevant records. SAPOL

requires original paper and electronic records and will not accept photocopies. It is an offence under the Coroners Act 2003 to hinder or obstruct a Coronial investigation.

6.1.2 When approached by SAPOL to provide department records, staff can refer the SAPOL officer to the Divisional Coronial Liaison Officer or manager or supervisor on duty to manage the request if this person is available and on site at the time. Otherwise, the staff member must, themselves, respond to the SAPOL request.

6.1.3 The Divisional Coronial Liaison Officer, manager, supervisor or other staff member managing a request from SAPOL must:

sight an authority, either a Coroner’s Direction to Enter or SAPOL general search warrant, before providing paper and electronic records and, with the consent of the SAPOL officer, retain a copy of the Direction or warrant

deliver the original documentation to SAPOL and whenever possible, keep copy(ies) of the files/records.

In some instances, the Coroner’s Direction to Enter may be sent electronically and the Coroner’s Office will dispatch a courier to collect the original documentation.

6.1.4 In addition, the staff member managing the request from SAPOL, must:

note the provision of records in the relevant divisional records management database(s)

keep a copy of the Direction to Enter or the general search warrant as a receipt for DCSI files

advise the Divisional Coronial Liaison Officer and DCSI Coronial Officer of the records that have been provided to SAPOL.

6.2 STATEMENTS AND OTHER INFORMATION6.2.1 If a staff member notifies the State Coroner or SAPOL of a reportable death they will be required to

provide the State Coroner or SAPOL with information and/or a formal statement in relation to the death (s28 Coroners Act 2003).

6.2.2 As part of a Coronial investigation, other staff members may also be approached by SAPOL to provide a formal statement of evidence and/or other information.

6.2.3 In these events:


the staff member must immediately inform their supervisor or manager

the supervisor or manager must immediately inform the Legal Services Unit, Divisional Coronial Liaison Officer and DCSI Coronial Officer

departmental policies and practices regarding obtaining legal advice should be followed.

Staff must not hinder or obstruct the Coroner’s powers of inquiry (s 23Coroners Act 2003).

6.2.4 If a staff member is required by SAPOL to give a statement:

the staff member (if an employee, not a contractor) may contact DCSI Legal Services Unit for support and direction in relation to the statement process

where the Crown Solicitor’s Office (CSO) has been instructed to act on behalf of the department and/or the individual employee, Legal Services Unit will liaise with the CSO to discuss the future conduct of the matter and whether or not a solicitor should be present while the statement is taken

the staff member must request a copy of the statement. However, before providing a copy of the statement, the SAPOL investigator will consider the person’s role and the circumstances of the investigation. If a copy of the statement is provided, the staff member must provide a copy of the statement to the Divisional Coronial Liaison Officer for inclusion in divisional records

the Divisional Coronial Liaison Officer must provide a copy of the statement to the Executive Director, Director, manager or supervisor, and to Legal Services Unit. They must also notify the DCSI Coronial Officer that a statement has been given.

7. Insurance

7.1 Upon becoming informed of a reportable death or Coronial investigation, the relevant Executive Director shall give immediate consideration to whether the death or other incident may have insurance implications for the department and, as required, discuss with the Legal Services Unit and DCSI Insurance Services whether the South Australian Insurance Corporation (SAICORP) should be advised.

8. Communication with the Coroner’s Office

8.1 Following a reportable death, or otherwise being informed that the Coroner is investigating the death of a client of interest to DCSI, the DCSI Coronial Officer shall, as soon as practicable, write to the Coroner’s Office requesting that DCSI be:

noted as an interested party in the death, explaining the nature of DCSI’s interest2

notified whether and when a Coronial inquest is to proceed

advised when a finding has been made by the Coroner about the death and of the terms of that finding.

2 In most instances this will be because the person was under the care or control of DCSI or the Minister


8.2 The DCSI Coronial Officer shall forward the details of any response(s) from the Coroner’s Office to the responsible Executive Director, Director, Legal Services Unit and the Divisional Coronial Liaison Officer.

9. Inquests of Interest to DCSI

9.1 ADVISE CHIEF EXECUTIVEInformation that a matter of interest to DCSI has been listed for inquest may come to the department through various channels. The staff member who receives this information must ensure that the Director, Legal Services, Director Business Affairs, the DCSI Coronial Officer, the relevant Executive Director and the Divisional Coronial Liaison Officer are immediately informed.

9.2 BRIEF MINISTERWithin 10 working days of being notified of the listing of an inquest, the Executive Director shall provide the Minister with a briefing. A copy of the briefing shall be provided to the Chief Executive, Director, Legal Services, Director Business Affairs, DCSI Coronial Officer, and the Divisional Coronial Liaison Officer.

9.3 LIAISE WITH CROWN SOLICITOR’S OFFICE (CSO)The Legal Services Unit shall liaise with the Crown Solicitor’s Office to:

where necessary, instruct CSO to represent the department

seek advice as to whether any employee requires separate legal representation

request to be notified of when an inquest is to commence and whether any employees are to appear as witnesses

request a copy of a Coroner’s Court finding(s) and recommendation(s) from CSO and, where necessary, a written report about the outcomes of an inquest.

9.4 INDEPENDENT LEGAL REPRESENTATIONIf the CSO cannot represent the department and/or the employee(s), due to a conflict of interest or otherwise, the Legal Services Unit will seek approval from the Crown Solicitor, consistent with the Treasurer’s Instruction 10, to obtain independent legal representation.


10. DCSI employees giving evidence at an inquest – Legal and Media assistance

10.1 LEGAL REPRESENTATION OF EMPLOYEES10.1.1 Department employees required to give evidence at an inquest will be provided with support by the

Legal Services Unit, in the first instance and where necessary, legal representation by the CSO. Employees may choose to obtain their own legal representation if they prefer.

10.1.2 Whenever CSO provides legal representation to an employee, assistance to the employee in preparing for and appearing at the inquest will be provided by the CSO in accordance with their general policies and practices for providing legal representation to State Government employees.

10.1.3 If consent is obtained for an employee to obtain independent legal representation in accordance with Treasurer‘s Instruction 10, the Legal Services Unit can assist the employee with administrative matters relating to the engagement of the practitioner and other general matters. The Legal Services Unit is not permitted to provide legal advice once an independent solicitor is engaged.

10.2 MEDIA ASSISTANCE10.2.1 In the event that an employee is required to give evidence at an inquest, the Media, Communications

and Events Unit can provide media-related support.

11. Coroner’s Court Findings and Recommendations

11.1 RELEASE OF FINDINGSThe DCSI Coronial Officer monitors the release of findings from the Coroner’s Court for known matters. However, advice that the Coroner has handed down findings can come to the Department through various channels (including via letter from the Coroner to the Minister and / or Chief Executive if recommendations are directed to the Department / Minister). Alternatively, the Crown Solicitor’s Office / Legal Services, DCSI Coronial Officer and / or external media may alert the Department to the handing down of Coronial Findings.

Following receipt of the Coroner’s Court (the Court) findings and recommendations, the DCSI Coronial Officer shall coordinate the following:

11.2 INITIAL BRIEFING TO MINISTERWithin 10 working days of the handing down of the Coroner’s Findings, the relevant division must provide the Minister with a briefing advising the findings and recommendations directed to the Minister and/or the department, if any.

If the death was a death in custody, and the Court has made recommendations directed to the Minister and/or the department, the brief shall include a reminder to the Minister of their obligation under section 25 (5) of the Act to table a report before each House of Parliament and to provide a copy to the Coroner within eight sitting days of the expiration of six months of receiving the findings and recommendations and shall specify the latest date on which the report can be tabled/provided.


11.3 RESPONDING TO RECOMMENDATIONS - DEATHS IN CUSTODYParagraph 11.3 applies to deaths in custody. For other reportable deaths, follow the guidelines in paragraph 11.4.

If the death was a death in custody and the Coroner has made recommendations directed to the Minister and/or DCSI, within six months of receiving those recommendations, a report is to be tabled in Parliament by the responsible Minister detailing any action(s) taken, or proposed actions to be taken by the department and/or the Minister in response to the Court’s recommendations. At this time, the Minister must forward a copy of that report to the Coroner.

The DCSI Coronial Officer will lead the development of the Parliamentary report (using the Parliament report template for Coronial matters), the Ministerial briefing and the Cabinet note and finalise for approval.

11.4 RESPONDING TO RECOMMENDATIONS – OTHER MATTERS11.4.1 Coordinate development of report for Coroner

Upon receipt of the Coroner’s findings, the DCSI Coronial Officer will contact the relevant business area(s) within DCSI, advise them of recommendations impacting on their area and seek input into a report for the Coroner, including information on actions taken (or proposed actions) in response to the recommendations.

11.4.2 Brief Minister

As soon as practicable, the relevant division must prepare a briefing to the Minister attaching that report. A draft letter from the Minister to the Coroner must also be included. Copies of the briefing must be provided to the DCSI Coronial Officer, the relevant Divisional Coronial Liaison Officer and the Legal Services Unit.

11.4.3 Report back to Coroner

Within six months of the publication of recommendations, a report detailing actions taken or proposed actions to be taken in response to the Coroner’s recommendations must be prepared by the relevant division. A briefing attaching that report and a draft letter from the Minister to the Coroner must also be included. Copies of the briefing must be provided to the DCSI Coronial Officer, the relevant Divisional Coronial Liaison Officer and the Legal Services Unit.

11.4.4 Periodic report to Chief Executive and Minister

The relevant division must co-ordinate reports to the Chief Executive / Minister regarding actions taken or proposed actions to be taken by the department in response to findings and recommendations when they are ongoing, not fulfilled or the Minister has decided not to act on a recommendation. Copies of the briefing must be provided to the DCSI Coronial Officer, the relevant Divisional Coronial Liaison Officer and the Legal Services Unit.

11.4.5 Communication

The DCSI Coronial Officer must ensure that relevant departmental staff are aware of the timing of reports being tabled in Parliament and that, where appropriate, copies of relevant documents are provided. This will ensure that appropriate responses to media and other enquiries can be made. Key people include Director, Business Affairs; Executive Director (responsible portfolio area(s)) and Manager, Media, Communications and Events Unit.


12. Reporting

12.1 The DCSI Coronial Officer shall provide bi-annual briefings to the Executive Leadership Team, detailing the status of all matters under investigation by the Coroner, or the subject of an inquest before the Coroner’s Court, in which DCSI has an interest, including DCSI’s response to the Coroner’s Findings and recommendations.


Appendix 1: DCSI roles & responsibilities The following arrangements outline responsibilities DCSI’s management of Coronial matters.

The Chief Executive is responsible for:

• Encouraging a culture of handling Coronial investigations and inquests seriously and thoroughly

• Ensuring an effective Coronial process is developed and in place for DCSI

• Ensuring appropriate actions are implemented in response to the Coroner’s findings and recommendations

• Ensuring the Minister is briefed on the findings and recommendations of inquests of interest to DCSI

• Ensuring the Minister has the necessary information to respond to any recommendations of the Coroner, in compliance with section 25 of the Coroners Act 2003.

Executive Directors of are responsible for:

• Ensuring their Directorates manage Coronial matters in line with the Coronial Policy and DCSI Coronial Guidelines and Mandatory Procedures, including the development, management and review of complementary divisional procedures

• Informing the Chief Executive, Legal Services Unit, DCSI Insurance Services, Director Business Affairs and the Minister, of any Coronial investigations or inquests of interest to DCSI which may highlight deficiencies in services or may otherwise lead to negative criticism of the department, the Chief Executive or the Minister

• Advising periodically of actions taken and planned in response to the events under investigation

• Ensuring their Directorates have at least one Divisional Coronial Liaison Officer

• Ensuring relevant divisional staff understand the Coronial Policy and Guidelines and Mandatory Procedures

• Ensuring contracts with service providers enable the their divisions to fulfil the Coronial Policy and Guidelines and Mandatory Procedures

• Ensuring their divisions have appropriate records management processes to meet the requirements of the Coronial Guidelines and Mandatory Procedures and any other related legal or policy requirements

• Ensuring the Minister(s) is provided with briefings on Coronial matters in accordance with the DCSI Coronial Guidelines and Mandatory Procedures

• Ensuring the development of a report to the Coroner in response to the Coroner’s recommendations

• Ensuring the development of a report for Parliament in response to the Coroner’s Court Findings and recommendations for deaths in custody

• Ensuring any recommendations from Coroner’s Findings are assessed and actioned

• Developing and implementing improvement strategies in response to the Coroner’s Findings and recommendations.


The DCSI Coronial Officer is responsible for:

• Monitoring and maintaining a central database of deaths reported to the Coroner, investigations and inquests of interest to DCSI, and Coroner’s Findings and recommendations

• Assisting the Chief Executive, Executive Directors, the Legal Services Unit and Divisional Coronial Liaison Officers in the management of the department’s participation in and monitoring of Coronial investigations and inquests

• Communicating with the Coroner’s Office and Divisional Coronial Liaison Officers to enable effective identification and monitoring of Coronial Investigations or Inquests of Interest to DCSI

• Communicating with the Coroner’s Office to ensure, wherever possible, the Coroner acknowledges DCSI’s interest in an investigation or inquest

• Assisting Divisional Coronial Liaison Officers, Executive Directors and the Legal Services Unit to identify reportable deaths and Coronial investigations and inquests of interest to DCSI

• Coordinating the preparation of a report to the Coroner detailing actions taken or proposed actions to be taken in response to the Coroner’s recommendations

• Coordinating the preparation of briefings to the Minister following the release by the Coroner of his findings and any recommendations following an inquest

• Leading the development of Parliamentary reports, Cabinet notes and Ministerial briefings in response to the Coroner’s Findings and recommendations for deaths in custody

• Communicating the timing of reports to be tabled in Parliament to relevant departmental staff and, where appropriate, providing copies of relevant documents

• Assisting divisions in informing staff on Coronial matters

• Providing bi-annual reports to the Chief Executive and Executive Leadership Team on the deaths reported by the department to the Coroner or SAPOL, and the status of Coronial investigations and inquests of interest to DCSI, including DCSI’s response to the Coroner’s Findings and recommendations.

Divisional Coronial Liaison Officers are responsible for:

• Monitoring and maintaining a divisional database of deaths reported to the Coroner, investigations and inquests of interest to DCSI, and Coroners’ Findings and recommendations

• Assisting Executive Directors, Directors, Director, Legal Services Unit and the DCSI Coronial Officer in the identification of reportable deaths and Coronial investigations and inquests of interest to DCSI

• Assisting Executive Directors, Directors, Director, Legal Services Unit and the DCSI Coronial Officer in the management of the department’s participation in and monitoring of Coronial investigations and inquests

• Assisting SAPOL and the Coroner with their investigations.


The Director, Legal Services Unit is responsible for:

• Managing the department’s legal representation at an inquest

• Assisting Executive Directors, Directors, the DCSI Coronial Officer and Divisional Coronial Liaison Officers in the identification of reportable deaths and Coronial investigations and inquests of interest to DCSI

• Assisting the Chief Executive, Executive Directors and the DCSI Coronial Officer in managing the department’s participation in and monitoring of Coronial investigations and inquests.

Directors, Managers and Supervisors are responsible for:

• Ensuring staff comply with the Coronial Guidelines and Mandatory Procedures and any complementary divisional procedures regarding reporting a reportable death to the Coroner or SAPOL and within DCSI

• Assisting Executive Directors and Directors with the preparation of briefings on Coronial matters in accordance with the DCSI Coronial Guidelines and Mandatory Procedures

• Assisting Executive Directors and Directors with the preparation of reports to the Coroner in response to the Coroner’s recommendations

• Assisting Executive Directors and Directors with the preparation of a report for Parliament in response to the Coroner’s Court Findings and recommendations for deaths in custody

• Reporting to Executive Directors and Directors periodically about actions taken and planned in response to matters under investigation

• Supporting staff required to give evidence to a Coronial investigation or inquest

• Assisting SAPOL and the Coroner with their investigations


Staff are responsible for:

• Notifying the Coroner of reportable deaths in compliance with the Coroners Act 2003, as well as the appropriate departmental officers

• Assisting SAPOL and the Coroner with their investigations

• Recording and securing all details related to the Coronial matter as soon as practicable in Riskman (or C3MS for Youth Justice).

Funded organisations are responsible for:

• Reporting reportable deaths to SAPOL or the Coroner and to the appropriate DCSI officers

• Ongoing liaison with the Department regarding the management of Coronial matters

• Ensuring clear instructions are in place for staff and their organisational guidelines are followed

• Reviewing Coronial matters



Appendix 2: Guide to determining reportable deaths

Upon becoming aware of a death, a staff member must immediately consider whether the death is a reportable death under the Coroners Act 2003.

The questions below are a guide to help determine whether a death is a reportable death. If the answer to any of the questions is, or could be, YES, then the death is reportable.

A death in custody is a special instance of a reportable death.

Deaths in custody must be reported immediately by phone to the Coroner’s Office. All other reportable deaths must be reported immediately by phone, to SAPOL or the Coroner’s Office. If in any doubt – either about whether the death is reportable or whether it has already been reported – the staff member or their delegate must report the death. Failure to report a reportable death is an offence.

Deaths in Custody: report the death to the Coroner’s Office onlyWas the person detained under any Act or law, including any Act or law providing for home detention? Was the person in the process of being apprehended or being held at any place by a person authorised to do so under any Act or law of the State or by a person authorised to do so under the law of any other jurisdiction?Was the person evading apprehension by any authorised person?Was the person escaping or attempting to escape from any place or authorised person?

Other Reportable Deaths: report the death to the Coroner’s Office or to SAPOLWas the death unexpected, unnatural or unusual?Was the death due to an accident, suicide, heat stroke, drowning, choking, or following an apparent improvement in general health?

Was the death in violent or suspicious circumstances?Is there evidence of recent assault? Are there any factors surrounding the death that seem inconsistent or difficult to explain?

Was the cause of death unknown?Was the death within 24 hours of being discharged from hospital, or the person having sought emergency treatment at a hospital?Was the death during or as a result, or within 24 hours, of a surgical, invasive or diagnostic procedure including an anaesthetic for the purposes of conducting a procedure?Was the person protected under the Guardianship and Administration Act 1993?People with mental incapacity may be protected through the appointment of a guardian for the protection of their personal wellbeing and/or through the appointment of an administrator, who manages their estate. Check the ‘Legal Documents’ section of the client record.

Was the person protected under the Aged and Infirm Persons’ Property Act 1940?People who by reason or age, illness, or impairment, are unable to manage their affairs or are liable to be


subjected to undue influence regarding their estate, may be protected under this Act. Check the ‘Legal Documents’ section of the client record.

Was the person in the custody of or under the guardianship of the Minister under the Children’s Protection Act 1993?Was the person a patient in an approved treatment centre under the Mental Health Act 1993?Was the person a resident of a licensed supported residential facility under the Supported Residential Facilities Act 1992?Was the person accommodated in a hospital or other treatment facility for the purposes of being treated for drug addiction?Was the death during, as a result of, or within 24 hours of receiving medical treatment to which consent has been given under Part 5 of the Guardianship and Administration Act 1993? People with a mental incapacity may not be able to consent to medical treatment. This law enables guardians, relatives and/or the Guardianship Board to provide that consent.

Was the cause of death not certified by a doctor?
