Coronial Liaison Unit

The Coronial Liaison Unit (CLU) was established in 2005, and aims to improve communication between the Department of Health and the coronial system.

The CLU:

  • coordinates instructions to the State Solicitor’s Office (SSO) during an inquest that may relate to the Department of Health
  • reviews all health related inquest findings
  • disseminates findings to appropriate stakeholders for information and/or to seek expert advice
  • provides advice back to the Chief Medical Officer on the implementation of coronial recommendations
  • coordinates, on a biannual basis, WA Health’s response to the State Coroner in relation to coronial recommendations
  • ensures non-inquested cases have been duly investigated under local health service mortality review processes where appropriate.

The coronial system

The coronial system, incorporating the Coroners Court (external site), has the power to investigate deaths reported under the Coroners Act 1996 (external site). Reportable deaths can be investigated confidentially or via public inquest.

Reporting a death

The notification of a reportable death to the Coroner is a statutory obligation and should be undertaken as soon as possible after a death occurs (maximum of 24 hours). A reportable death is defined in the Act (external site).

The process is outlined on the Death in hospital form (PDF 118KB). It is a mandatory document related to the Review of Death Policy, which establishes the minimum information required to be collected when a patient dies in hospital, and includes information about how to report a death to the Coroner.

Please note: WA Police Coronial Investigation Squad (CIS) phone numbers identified on the current death in hospital form have changed from the previous form (see below). Facsimile (fax) will no longer be used (from December 2020) and will be replaced wit a dedicated email address.

To report a death to the Coroner, or to seek guidance about reportable deaths, healthcare workers must contact the appropriate police unit.

Death in hospital and removal of medical devices and equipment fact sheet (WA Health staff only) is available for Health Service Providers in providing further guidance about management of care of the deceased once a death has been reported to the Coroner.

Metropolitan Perth

Contact the WA Police Coronial Investigation Squad (CIS) on 08 9267 5700 (24 hours-a-day, 7 days-a-week). Scan and email the Death in Hospital form to:

Country WA

Contact the local police. If further guidance or assistance is required, contact the CIS on 08 9267 5700.

The Office of the State Coroner (OSC) can be contacted on 08 9425 2900 (business hours) if the CIS and local Police are unable to assist.

For further information on reportable deaths contact the Department’s Legal and Legislative Services. 

Inquest findings

Inquest findings are added to the Coroner’s Court of Western Australia website (external site) once released. Inquest findings are listed by year of release. It is important to note that not all inquest findings released will have health-related recommendations.

Progress report for Health-Related Coronial Recommendations

The Coronial Liaison Unit provides biannual updates on the implementation of inquest recommendations to the State Coroner.

From Death We Learn

From Death We Learn is an annual publication of reviews of health-related coronial inquest findings that provide key messages, recommendations and actions taken by the WA health system to address the Coroner's concerns.

More information

Patient Safety Surveillance Unit

Last reviewed: 20-11-2023
Produced by

Patient Safety Surveillance Unit