Form 03 - Doctor`s notice to coroner after autopsy

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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
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