Report 6: 2018–19
Report type

Audit Objective

In this audit, we assessed whether agencies are effective and efficient in supporting the coroner in investigating and helping to prevent deaths. We examined whether agencies:

  • provide adequate support to bereaved families
  • have efficient and effective processes and systems for delivering coronial services
  • plan effectively to deliver sustainable coronial services.


Queensland coroners are responsible for investigating deaths that occur in Queensland under certain circumstances. Their primary responsibility is to make formal findings in respect of the death, including the circumstances and cause of the death.

Between 2011–12 and 2017–18, the number of deaths reported to the coroner each year for investigation increased by 27 per cent. Demand for Queensland's coronial services is likely to increase with the state’s growing and ageing population.

An effective and efficient coronial system will enable a coroner to provide timely and reliable answers. However, Queensland’s coronial system is complex, and coroners rely on the services of multiple public sector and contracted agencies across a geographically dispersed state.


Department of Justice and Attorney-General, Department of Health, Queensland Police Service, and the Department of Premier and Cabinet

We recommend the Department of Justice and Attorney-General, in collaboration with the Department of Health, Queensland Police Service, the Department of Premier and Cabinet, and the coroners: 

1. establish effective governance arrangements across the coronial system by:

  • creating a governance board with adequate authority to be accountable for coordinating the agencies responsible for delivering coronial services and monitoring and managing the system’s performance. This board could be directly accountable to a minister and could include the State Coroner and Chief Forensic Pathologist
  • more clearly defining agency responsibilities across the coronial process and ensuring each agency is adequately funded and resourced to deliver its services
  • establishing terms of reference for the interdepartmental working group to drive interagency collaboration and projects, with consideration of its reporting and accountability. This should include its accountability to the State Coroner and/or a governance board if established.

2. evaluate the merits of establishing an independent statutory body with its own funding and resources to deliver effective medical services for Queensland’s justice and coronial systems.

Department of Justice and Attorney-General, Department of Health, and the Queensland Police Service

We recommend that the Department of Justice and Attorney-General, Department of Health, and the Queensland Police Service, in collaboration with coroners:

3. improve the systems and legislation supporting coronial service delivery by:

  • identifying opportunities to interface their systems to more efficiently share coronial information, including police reports (form 1s), coroners orders and autopsy reports
  • reviewing the Coroners Act 2003 to identify opportunities for improvement and to avoid unnecessary coronial investigations. This should include considering the legislative changes to provide pathologists and coronial nurses with the ability to undertake more detailed preliminary investigations (such as taking blood samples) as part of the triage process
  • reviewing the Burials Assistance Act 1965 and the burials assistance scheme to identify opportunities for improvement and provide greater ability to recover funds. This should include a cost benefit analysis to determine the cost of administering the scheme against improved debt recovery avenues.    

4. improve processes and practices across the coronial system by:

  • ensuring the Coroners Court of Queensland appoints appropriately experienced, trained and supported case managers to proactively manage entire investigations and be the central point of information for families. This should include formal agreement from all agencies of the central role and authority of these investigators
  • ensuring there is a coordinated, statewide approach to triaging all deaths reported to coroners to help advise the coroner on the need for autopsy
  • establishing processes to ensure families receive adequate and timely information throughout the coronial process. This should include notifying families at key stages of the process and periodically for investigations that are delayed at a stage in the process
  • ensuring sufficient counselling services are available and coordinated across agencies to support families and inquest witnesses.

5. assess more thoroughly the implications of centralising pathology services and determine which forensic pathology model would have the best outcomes for the system, coroners, and regions, and the families of the deceased.

Department of Justice and Attorney-General

We recommend the Department of Justice and Attorney-General:

6. implements a strategy and timeframe to address the growing backlog of outstanding coronial cases. In developing and implementing this strategy it should collaborate with the Department of Health, Queensland Police Service, and coroners

7. improves the performance monitoring and management of government undertakers. This should include taking proactive action to address underperformance where necessary in accordance with the existing standing offer arrangements.