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Interpreting the Coroners Act at the bedside: how do junior doctors know they are doing it correctly?

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To the Editor: Interpreting coronial legislation can prove challenging for junior doctors at the bedside, with significant local variation in interpretation.1 The Victorian Coroners Act (Coroners Act 2008 [Vic]) has recently undergone changes that have coincided with a decline in numbers of reported cases,2 with the Coroners Court raising the question of whether there was “unintentional under-reporting of reportable deaths”.2 What constitutes a reportable death under that Act is summarised in the Box.

Austin Health has a well established medicolegal support for junior doctors (formal education sessions, internal website and medical administration advice available 24 hours a day). However, it was unclear whether there was a failure to report reportable deaths, leading to unintentional underreporting of deaths to the Coroner.

Austin Health was involved in 82 coroners’ cases in 2011, of which 68 were reported directly by Austin Health. In addition to our usual clinical review of all reported coroners’ cases, the 14 cases that were externally referred (including from Births, Deaths and Marriages Victoria) were specifically analysed…