Printed case number, name and barcode on sticker Form 3, Version 4 QUEENSLAND CORONERS ACT 2003 (Section 24) DOCTOR’S NOTICE TO CORONER AFTER AUTOPSY SECTION A – to be completed by the doctor who has performed the autopsy immediately following autopsy To the coroner at: (print place) ________________________________________ 1. The following autopsy examination has been conducted on the body of: whose date of birth was: (print name of deceased person) on: (print date of birth) at: (print date of autopsy examination) (print place autopsy conducted) in accordance with the order for autopsy and autopsy testing dated (print date of autopsy order) 2. Does the pathologist wish to retain prescribed tissue? (please tick) Note: “Prescribed tissue” means whole organs, identifiable body parts, and a foetus removed from a pregnant woman, see State Coroner’s Guidelines. Yes: already authorised by coroner: please confirm details in sections 3 and 4 Yes: coroner’s decision is now sought: please provide details in sections 3 and 4 No: go straight to section 5 3. Prescribed tissue pathologist wishes to be retained for testing, examination or evidence: Please tick or specify the tissue sought and type of testing, etc intended Brain / Spinal cord for neuropathology Portion of bone: spine skull Whole heart for detailed cardiac pathology For: rib examination other ________________ tool mark analysis evidence Whole lung for volatiles toxicology (glue etc) _______________________________________________________ (specify) One / both eyes for dissection and histology _______________________________________________________ (specify) 4. Summary of reasons why retention of prescribed tissue is necessary for the investigation of the death: 5. Non-prescribed tissue kept for testing or evidentiary purposes: Note: “Tissue” includes blood and body fluids. “Non-prescribed tissue” refers to tissue other than whole organs, foetuses or identifiable body parts. Non-prescribed sample/tissue kept Tests Arranged Ordered by Coroner Please tick or specify as needed Please tick Please tick Tissues in formalin: cassettes / wet tissue (please circle) Blood, urine, vitreous, stomach contents, liver, hair, body cavity fluid _________________________________________________(specify) Samples for infant death: skin, heart, liver, trachea, lung, metabolic Guthrie card, skeletal muscle, blood FTA card for DNA (plus other samples if needed) Histology Toxicology: full rapid limited hold only Yes No Yes No Cytogenetics, microbiology & metabolic studies, etc No Forensic DNA Analysis No Other: Form 3 Version 4 – 18 July 2011 1 6. Cremation Risks (pacemakers, radioactive implants, or other implanted devices): (please tick one of the following Printed case number, name and barcode on sticker To the best of my knowledge and belief, based on my examination of the deceased, there are no pacemakers or other implanted devices that would pose a cremation risk. I found in the course of my examination a ____________________________________________________________ and removed this device. To the best of my knowledge and belief, there is no further cremation risk. I am unable to advise whether any pacemakers or other implanted devices that would pose a cremation risk are present. 7. Infection Risk: (please tick one of the following) The deceased is not known or suspected to be suffering from any infectious disease that presents a risk to those transporting the body if transported and handled using standard infection control measures. The deceased may present an infection risk. Further advice should be sought as to the infection control measures required. I am unable to advise about infection risk as there is insufficient information. Standard infection control must be used. 8. Cause of Death: (please tick one of the following) I have completed an autopsy certificate (Form 30) I have completed an autopsy notice (Form 29) I have not completed either because the deceased is not identified. 9. Is the body ready for release? (please tick or give details below as necessary) Is tissue donation (if any) complete? Yes No: but will be within 24 hours Not applicable Is examination of the body complete? Yes No: but will be within 24-48 hours Other: details below Is all prescribed tissue returned to body? Yes No: but will be within 24-48 hours Other: details below Is the body formally identified, as per Police Report (Form 1 or Supplementary Form 1)? Yes No: but likely within 24-48 hours: Form 29/30 will be issued when ID confirmed by police (Supplementary Form 1) Dental ID, DNA, etc needed as detailed below: coroner can release once satisfied about ID Details: 10. Summary of pathologist’s main macroscopic autopsy findings (positive and negative) and any other comments: 11. I recommend that reports/statements be obtained from: (please tick whichever apply and give details) Medical records (if not already arranged via Form 5) Treating doctors nurses paramedics Medical specialist (note relevant speciality) Other __________________________________________________ in relation to the following issues: Doctor's signature: Date: Doctor’s name: (print name) Office telephone no: Form 3 Version 4 – 18 July 2011 Mobile no: Fax: 2 SECTION B – CORONER’S ORDER REGARDING PRESCRIBED TISSUE Section B is a stand-alone form which should be completed urgently and emailed or faxed to the mortuary In respect of the circumstances surrounding the death of: ____________________________________________________________ (print name of deceased person) _____________________________________________________________ I, (print name of coroner and title) have considered: the pathologist’s reasons for wishing to retain prescribed tissue, and the following concerns raised about the proposed retention: and have made the following decisions about whether the retention is/is not necessary for the investigation of the death, despite the concerns raised, for the reasons given below: Prescribed tissue (List all prescribed tissue as per Section A) Coroner’s decision: is retention necessary? Yes No Yes No Yes No Reasons for coroner’s decision (specify) Based on the above, I order that the prescribed tissue: (tick one only and complete details) be returned to the body immediately after appropriate examination and sampling before the body is released or, after undergoing testing, examination or evidentiary use: be returned to the body by / within ________________________________(specify date or time period) before the body is released be retained as necessary and disposed of in accordance with the family’s wishes I also order that the testing, examination, evidentiary use and retention (if any) and subsequent disposal be subject to the following conditions: (specify any conditions applicable) Date of order: Place where order made: Name of person making order: Signature of person making order: Confirmation by pathologist / mortuary that the coroner’s order has been carried out (Please tick one only, complete the details and email or fax to the coroner) I confirm that prescribed tissue, namely was returned to the body on: (date) Or I confirm that prescribed tissue has been retained and will be disposed of in accordance with the family’s wishes Signature: Name: Form 3 Version 4 – 18 July 2011 Pathologist Date: Place: Scientist Mortuary Assistant Phone: 3