Glossary of Terms

In this situation a cause of death has not been ascertained by the forensic pathologist.

This refers to a death of a person which occurred due to an unforeseen misfortune or mishap resulting in some physical injury or harm which has a causal connection with that death.

Examples of accidental deaths include industrial disasters, falls, drowning, burning, electrocution and motor vehicle accidents.

This refers to a death caused by human error. It occurs in a situation where a person, in the doing of a lawful act and without any intention to injure another, accidentally kills that other person.

Thus a medical investigation or anaesthetic which results in death would be a death by misadventure.

This term refers to the situation in which a full investigation and inquiry has taken place, and the cause of the death is not known. Insufficient evidence has not allowed the Coroner to find a definite cause of death.

For example, a coronial inquiry into the cause of death of a body found at sea may suggest more than one possible cause of death.

Natural death means death as a result of disease or bodily infirmity which has not occurred as a result of an external source.

A non-natural death is one where the person dies directly and consequently from a definable external event or intervention.

The Coroners Act 1996 states a reportable death means a Western Australian death:

1. that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury;
2. that occurs during an anaesthetic;
3. that occurs as a result of an anaesthetic and is not due to natural causes;
4. that occurs in prescribed circumstances;
5. of a person who immediately before death was a person held in care;
6. that appears to be caused or contributed to while the person was held in care;
7. that appears to have caused or contributed to by any action of a member of the Police Force;
8. of a person whose identity is unknown;
9. that occurs in Western Australia where the cause of death has not been certified under section 44 of the Births, Deaths and Marriages Act 1998; or
10. that occurred outside Western Australia where the cause of death is not certified to by a person who, under the law in force in that place, is a legally qualified medical practitioner.

Any Western Australian death which occurs that does not come under the Coroners Act 1996, and listed as a reportable death.

A sentinel event refers to a rare event that leads to a catastrophic patient outcome. An example would be the administration of a drug resulting in a patient death, removal of the wrong body part, retained instruments or maternal deaths.

All sentinel events are reported to the Chief Medical Officer of the Department of Health.

A judicial officer, like a judge, who investigates the causes and circumstances of a death and considers whether any recommendations can be made that might reduce the chances of deaths occurring in similar circumstances in the future.

The coroner’s written decision about the causes and circumstances of death. This is provided at the end of the coronial process.

This is a public courtroom hearing where a coroner hears from witnesses about the facts relating to the death. Usually anyone may attend.

The coroner’s formal investigation to look into the causes and circumstances of a death. This is not public.

A specially trained doctor who examines bodies to identify the medical cause of death.

An autopsy. A pathologist’s medical examination of the body of the person who has died.