Impact of coronial investigations on manner and cause of death determinations in Australia, 2000-2007

Med J Aust. 2010 Apr 19;192(8):444-7. doi: 10.5694/j.1326-5377.2010.tb03582.x.


Objective: To evaluate the changes in the understanding of the manner and cause of death occurring during the course of coronial investigations.

Design: Retrospective analysis of deaths reported to coroners in Australia between 1 July 2000 and 31 December 2007, using the National Coroners Information System.

Main outcome measures: (i) Manner of death (natural, external, unknown); (ii) intent classification (eg, unintentional injury, suicide, assault) among deaths with external causes; and, (iii) changes in the manner of death and intent classification between the presumption made at case notification and the coroner's final determination.

Results: The coronial investigation changed the presumption about manner of death or intent classification in 5.2% (6222/120 452) of cases in which a presumption was made. Among deaths with a change in attribution from natural causes to external causes, unintentional falls (442/1891) and pharmaceutical poisoning (427/1891) each accounted for 23%. Among deaths with attribution changing from external causes to natural causes, the leading medical causes of death were cardiovascular compromise (551/842; 65%) and infection (124/842; 15%). Of deaths understood correctly at notification to be due to external causes, but the wrong external cause, 34% (206/600) were ultimately judged to be unintentional injuries, and 22% (133/600) were judged to be suicides.

Conclusions: Coronial investigations transform basic understanding of cause of death in only a small minority of cases. However, the benefits to families and society of accurate cause-of-death determinations in these difficult cases may be considerable.

Publication types

  • Evaluation Study

MeSH terms

  • Adolescent
  • Adult
  • Age Distribution
  • Age Factors
  • Aged
  • Australia / epidemiology
  • Autopsy / methods*
  • Autopsy / statistics & numerical data*
  • Cause of Death* / trends
  • Coroners and Medical Examiners / organization & administration*
  • Death Certificates*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Mortality* / trends
  • Retrospective Studies
  • Sex Distribution
  • Sex Factors
  • Wounds and Injuries / classification*
  • Wounds and Injuries / mortality
  • Young Adult