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  • Writer's pictureThe Communiqués

Clinical Communiqué Volume 4 Issue 4 December 2017

In this edition

  • Editorial

  • Case #1 Standing Alone

  • Case #2 A protracted procedure

  • Case #3 Doubling the risks

  • Expert Commentary Helping clinicians better understand the coronial process


Welcome to the December 2017 edition of the Clinical Communiqué. For the final edition of the year, we have chosen to present a selection of cases that demonstrate some of the important non-clinical aspects of coronial investigations and inquest findings.

Each case provides an example of the variations seen in the ‘procedural history’ of an inquest. That is, the ‘what happened’ in the course of the coronial investigation. Factors such as the purpose, timing, people involved, and the disposition of an investigation, are all worth consideration by clinicians when reading coroners’ findings. These factors are relevant to understanding why some cases go to inquest, and others don’t, and why a coroner may choose to investigate a selected topic in a particular manner.

Examples of these include an approach taken by a coroner into a case that is concurrently reviewed by an industry regulator (‘Standing Alone’), or the time it takes to finalise an investigation, and the use of experts (‘A Protracted Procedure’). Alternatively, as demonstrated in the case, ‘Doubling the Risks’, cases that go to inquest may be conducted either singly or grouped together, for the predominant purpose of exploring a wider public health issue, even when the clinical management in the events leading to the death are considered reasonable under the circumstances.

To complement our edition on coronial processes, we have the immense privilege of including an expert commentary written by Dr Ian Freckelton, an experienced Queen’s Counsel at the Victorian Bar. He has appeared in many of Australia’s most significant coronial inquests over the past 25 years, including latterly the inquest into the deaths at the Lindt Café in Sydney. He is currently briefed in the Bourke St Mall inquest and the Brighton Terrorist inquest. Ian is also a Justice of the Supreme Court of Nauru, a Professorial Fellow in Law and Psychiatry at the University of Melbourne, an Adjunct Professor of Forensic Medicine at Monash University, and a member of Victoria’s Coronial Council.

Ian’s commentary is designed as a response to the clinicians who have authored case summaries for the Clinical Communiqués over the years. These clinicians were asked to imagine that they were sitting with a lawyer experienced in coronial matters, and to pose questions that they would like answered. The result is the highly informative and extremely valuable commentary – ‘Helping Clinicians Better Understand the Coronial Process’.

The commentary refers to Victorian legislation, however, the Coroners Act for each State and Territory is easily accessible on the internet and clinicians should be aware of the relevant provisions in their own jurisdictions. The Coroners Court websites are important resources as well, with specific information about coronial processes, inquest findings, locations and contacts. A list of the websites for each of the Australian jurisdictions can be found on the Clinical Communiqué website via the following link

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