Police Report of Death for the Coroner
(Coroners Act 1995, Coroners Rules 2006, Rule 4)
SECTION 1 – DECEASED’S DETAILS
Deceased’s Demographics
Coroner’s case number
Gender
Male
Surname
Female
Unknown
Given names
Aliases (if known)
Date of death (between)
Marital status
Never Married
Date of birth
Married (including defacto)
Widowed
Age
Divorced
Usual address
Unknown
Suburb/Town
State
Residency
Permanent
Separated
Country
Itinerant
Homeless
Interstate Visitor
Postcode
Overseas Visitor
Unknown
Country of birth
Town/City
Usual occupation (during working life)
Employment status
Was deceased from non-English speaking background
Unknown
No
Yes (If Yes, specify)
Was deceased of Aboriginal or Torres Strait Islander origin (if both, tick ‘yes’ to both)
(Note: This question is worded to be consistent with Australian Bureau of Statistics requirements)
No
Yes, Aboriginal origin
Yes, Torres Strait Islander Origin
Were there other deaths associated with this incident
Unknown
No
Yes (If Yes, specify how many)
Medical Information
Did an ambulance attend the scene
Unknown
No
Yes
Was deceased treated by ambulance officers
Unknown
No
Yes
Were drugs administered by medic/paramedic prior to death
Unknown
No
Yes (If Yes, specify)
Usual treating doctor’s name (and relevant specialist practitioners)
Doctor’s address
Date last visited doctor
Police Report of Death for the Coroner > November 2011 (v.3)
Doctor’s contact number
Will doctor certify cause of death
No
Yes
Not Known
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Date doctor spoken to
Time doctor spoken to
Discussion details (If not spoken to, detail what attempts were made to identify and speak with doctor)
Known medical history
Unknown
No known history
Yes (If Yes, specify)
Was deceased known to be currently on prescribed medication
Unknown
No
Yes (If Yes, specify)
Was deceased currently on contraceptive medication
Unknown
No
Yes (specify below)
Not applicable
Contraceptive medication used by deceased
Duration contraceptive medication used
Has the deceased any surgical implants
Unknown
No
Yes
If yes, specify surgical implants
Cardiac Pacemaker
Cardiac Defibrillator
Surgical Implants (e.g. joint replacements)
Other (specify)
Was deceased a smoker
Unknown
No
Yes (If yes, specify daily quantity and duration)
Was deceased suspected of having an infectious disease at time of death
Unknown
No
Yes (If Yes, specify)
History
Did the deceased have a known history of any of the following
(Source of information may include medical record, police record, other official record, family/friends)
Criminal Record
Intellectual Disability
Time in Custody
Time in Mental Health Institution
Depression (detail source)
Psychiatric Illness (detail source)
Release from an institution within the last week (detail type)
SECTION 2 – LOCATION OF DEATH (TICK ONE BOX ONLY)
Home
Recreation area
Sport or Athletics Area
Street or Highway
Trade or Service Area
Mine or Quarry
Unknown
School / Other Institution / Public Administration Area
Correctional Facility (e.g. prison, youth training centre)
Residential Facility (e.g. retirement village)
Farm (not including farm house)
Hospital or other Health Service
Industrial or Construction Area
Other (specify)
SECTION 3 – ACTIVITY AT TIME OF INCIDENT (TICK ONE BOX ONLY)
Leisure Activity
Domestic Duties
Nursed / Cared For
Other (specify)
Sports and Active Recreation
Engaged in Formal Education (student)
Resting / Sleeping / Eating / Personal Activity
Working for Income
Volunteer Work
Unknown
SECTION 4 – CAUSE OF DEATH DETAILS
Apparent Case Type
Suspected Suicide
Homicide
Accident
Police Report of Death for the Coroner > November 2011 (v.3)
Natural
Unknown
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Is this death directly related to family violence?
No
Yes (If yes, provide FVMS number)
Apparent Cause of Death
Incident Circumstances (tick one or more boxes and ensure you complete the addition section as specified)
Natural
Drowning / Water Related Death (section 15)
Work Related Death (section 8)
Unexpected Infant / Child Death (section 16)
Hospital Death
Consumer Product Related Death (section 9)
Death Involving an Anaesthetic
Death Involving a Weapon / Firearm (section 10)
Hanging Death
Fire / Burn Related Death (section 11)
Homicide
Transport Related Death (section 12)
Missing Person
Drug / Alcohol / Poison Related Death (section 14)
Suspected Suicide (section 13)
Unknown
Other (specify, e.g. electrocution, fall, sporting)
SECTION 5 – INCIDENT DETAILS
Coroner’s case number
CACS number
Incident date
Approximate incident time
Offence Report number
Location address
Suburb/Town
State
Postcode
Found Dead / Dying
Date
Approximate time
Location address
Suburb/Town
State
Postcode
Found By (name)
Phone (home)
Phone (mobile)
Address
Postcode
Last Seen Alive
Date
Approximate time
Location address
Suburb/Town
State
Last Seen By (name)
Phone (home)
Police Report of Death for the Coroner > November 2011 (v.3)
Postcode
Relationship
Phone (mobile)
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Address
Postcode
Next of Kin details
Senior Next of Kin
Title
Mr
Relationship to deceased
Phone (work)
Mrs
Miss
Phone (home)
Ms
Phone (mobile)
Address
Postcode
Does the senior next of kin object to post mortem
No
Yes (if yes, a written objection is required)
Does the senior next of kin authorise disposal of clothing worn by the deceased
No
Yes
Identification details
Has deceased been identified
No
Yes
If ‘Yes’ (deceased has been identified) by whom
Title
Mr
Mrs
Miss
Ms
Relationship
Phone
Address
Postcode
If ‘No’ (deceased has not been identified) have arrangements been made for identification
No
Yes
If ‘Yes’ (arrangements have been made for identification of deceased) by whom
No
Yes
Relationship
Phone
Address
Postcode
SECTION 6 – SUMMARY OF INCIDENT
Have or will charges be laid in relation to the death
Unknown
No
Yes (If Yes, detail charges)
Summary of circumstances (full and comprehensive details of events leading to the death and of the scene)
Items taken possession of
(include Property Receipt(s) and location details)
Was a Daily Incident Sheet submitted?
No
Yes (If Yes, attach a copy of the incident sheet)
Did CIB/DIS attend?
No
Yes (If Yes, specify who attended)
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SECTION 7 – REPORTING INFORMATION
Name of person reporting death to police
Date
Time
Phone
Address
Postcode
Reporting Police Member Details
Surname
Given name
Rank
Badge number
Station
Phone
Fax
Signature
Investigating Police Officer
Surname
Given name
Rank
Badge number
Station
Phone
Fax
Signature
SECTION 8 – WORK-RELATED DEATH (at work, travelling to/from work or travelling as part of work)
Did death occur while
Working (includes travelling for work)
Not known if working or commuting
Travelling to/from work (commuting)
Occupation at time of death (if different from usual occupation)
Industry
Were Workplace Standards notified?
No
Yes
Are Workplace Standards investigating death?
No
Yes
SECTION 9 – CONSUMER PRODUCT-RELATED DEATH
Did the death involve any of the following in relation to a product or safety device?
Defect
Malfunction
Misuse
Design Fault
Inherent Safety Problem
Other Problem (specify)
Type and description of product
Make and model of product
Approximate age of product
Police Report of Death for the Coroner > November 2011 (v.3)
Place of purchase
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SECTION 10 – DEATH INVOLVING A WEAPON/FIREARM
Type of weapon
Firearm (complete 10.1)
Other weapon (specify)
Who inflicted fatal wound
Deceased
Other person
Unknown
10.1 Firearm
Type of firearm (e.g. make, model, type, action, calibre, category)
Was the firearm registered
Unknown
No
Yes
If Yes, to whom
Deceased
User (if not deceased)
Other
Unknown
Was the user licensed to use that category of firearm?
Unknown
No
Yes
SECTION 11 – FIRE/BURN RELATED DEATH
Setting of incident
Private Building
Public Building
Outdoor Area
Other (specify)
If Building, were smoke alarms present?
Unknown
No
Yes
If Yes, were they activated?
Unknown
No
Yes
Was a sprinkler system present?
Unknown
No
Yes
If Yes, was it activated?
Unknown
No
Yes
Were there barriers to escape?
Unknown
No
Yes
If Yes, specify
Locked exits
Barred windows
Other (specify)
SECTION 12 – TRANSPORT-RELATED DEATH
(does not include water-vessel. Describe road/trail and weather conditions in summary of incident)
Types of vehicles involved in incident
Motor Vehicle
Motor Cycle
Other (specify)
Number of vehicles involved
Role of the deceased at time of incident?
Driver / Rider or Pilot
Passenger
Tram/light rail
Train
Aircraft
Bicycle
Area speed limit
Pedestrian
Cyclist
Other (specify)
Is drug/alcohol involvement suspected?
Unknown
No
Yes
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Vehicle/Aircraft
Descriptions
Type (e.g. car, plane,
motorcycle)
Make/Model/
Description
Year
Deceased’s
Vehicle
Speed Category
within limit
possibly over
likely over
definitely over
N/A
Vehicle 2
within limit
possibly over
likely over
definitely over
N/A
Vehicle 3
within limit
possibly over
likely over
definitely over
N/A
Vehicle 4
within limit
possibly over
likely over
definitely over
N/A
Was the deceased wearing a seat belt?
N/A
Unknown
No
Yes
Were airbags installed and activated?
N/A
Unknown
No
Yes (specify below)
Airbags installed
Driver
Front Passenger
Right Side
Left Side
Right Side
Left Side
Other (specify)
Airbags activated
Driver
Front Passenger
Other (specify)
If cycle rider, was helmet being worn?
Unknown
No
Yes
SECTION 13 – SUSPECTED SUICIDE
What evidence is there to indicate that the deceased intended suicide)
Statement to Family/Friends
Statement to Health Professional
Note/Letter
Other (specify)
Had the deceased previously attempted suicide?
Unknown
No
Yes (If Yes, specify approximate number of times)
Has the deceased previously sought medical treatment for self harm?
Unknown
No
Yes (If Yes, specify approximate number of times)
Is there any possible motive/trigger for the suicide?
Relationship Breakdown
Sexual Abuse
Loss of a Loved One
Illness
Alcohol/Drug Dependency
Unknown
Other (specify)
Police Report of Death for the Coroner > November 2011 (v.3)
Financial Problems
Prospect of Criminal Sanction
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Was deceased being treated/seen by any of the following professionals?
General Practitioner
Psychiatrist
Psychologist
Case Manager
Was the death accompanied by the murder/suicide of other persons(s)?
No
Yes
If Yes, who?
If Yes, what was the relationship between the deceased and the person(s)?
Were Standby Response Pamphlets provided to the family?
No
Yes
SECTION 14 – SUSPECTED DRUG/ALCOHOL/POISON RELATED DEATH
Was there evidence of drug/alcohol/substance use?
No
Yes
Is Yes, specify details
Alcohol or empty containers (describe below)
Prescription or over-the-counter drugs (describe below)
Illicit/prohibited drugs (describe below)
Poisons or gases (including carbon monoxide) (describe below)
Injecting or other drug paraphernalia (e.g. needles, syringe, bong, straw) (describe below)
Statement by deceased prior to death or by witness (describe below)
Items related to volatile substance abuse (e.g. petrol, paint, glue) (describe below)
Other (specify below)
Did DIS attend?
No
Yes (If yes, specify who attended)
Suspected Drug/Substance Abuse (Excluding Alcohol)
Apparent substance(s) used (if known)
Date of last use
Administered by
Unknown
Self
Time of last use
Other
Location of last use
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Symptoms of drug use
When symptoms first appeared
Was there evidence of drug/substance administration on the body of the deceased
Unknown
No
Yes
If Yes, what? (e.g. injection marks, powder on nose)
Route of administration
Unknown
Oral
Injection
Inhalation
Other (specify)
History
Did the deceased have a history of any of the following?
(Source of information may include medical record, police record, other official record, family/friends)
Abuse of alcohol (specify source)
Abuse of prescription of over-the-counter drugs (specify source)
Abuse of volatile substances (e.g. petrol, glue, paint) (specify source)
Exposure to poisons or gases (specify type and source)
Drug treatment program(s) (specify type and source)
Abuse of other drugs (specify source)
heroin or other opiates
amphetamines
cocaine
marijuana
type unknown
other (specify)
Prescription Medication
Was the deceased recently prescribed any medication?
Unknown
No
Yes
If Yes, specify date
Prescribing doctor name
Address
Postcode
Phone
List the drug(s) and quantities prescribed and amount remaining
SECTION 15 – DROWNING/WATER-RELATED DEATH
Type of aquatic environment
Public place
Private place
Location
Bathtub
Dam
Ocean
River
Other (specify)
Beach (non-surf)
Beach (surf)
Lake
Bucket/Container
Spa (external)
Spa (internal)
Harbour/Bay
Irrigation Channel
Police Report of Death for the Coroner > November 2011 (v.3)
Swimming Pool (in ground)
Swimming Pool (above ground)
Pond/Ornamental Lake
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Activity at Time of Incident
Activity
Fishing (including spear fishing)
Attempting a Rescue
Swimming, Paddling or Wading
Incident Involving a Water Vessel
Water-skiing
Unknown, no witness
Skin Diving / Snorkelling
Diving (e.g. Scuba/SSBA/Platform)
Walking/Playing Near Water
Board Riding (e.g. Surfing, Body Boarding)
Bathing
Other (specify)
Does the activity involve any of the following
Injury/Accident
Fell/Wandered/Jumped into water
Hypothermia
Swept away by water (e.g. off ricks, by rip)
Deceased’s Swimming Ability
Strong
Competent
Weak
Non-swimmer
Unknown
Death Involving a Water Vessel
Did the death involve a water vessel?
Yes
No (go to ‘Supervision’)
If Yes, was the vessel
Motorised Water Vessel
Non-Motorised Water Vessel
Type of vessel
Commercial
Motorised Personal Watervessel (PWV) e.g. Jet Ski
Recreational
Unknown
Number of people on board the vessel
Were life jackets / personal floatation devices available on the vessel?
Unknown
No
Yes
If Yes, was a life jacket/personal floatation device worn by the deceased?
Unknown
No
Yes
Note: All water craft, including motors, diving equipment, etc. and all safety and/or protective clothing
(e.g. waders, wetsuits, etc.) worn by the deceased at the time are to be retained for examination.
Supervision
Was the deceased under supervision
Unknown
No
Yes
If Yes, by whom
Describe the extent and level of the supervision
Was the area being patrolled by life guards at the time
Unknown
No
Yes
N/A
Conditions at Time of the Incident
What were the prevailing environmental conditions where the death occurred
Weather
Unknown
Clear
Hazy
Cloudy
Rain
Flood
Wind
Unknown
None
Light
Moderate
Strong
Gale
Police Report of Death for the Coroner > November 2011 (v.3)
Fog
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Tide
Unknown
In
Waves
Unknown
< 1 metre
Out
1-2 metres
> 2 metres
Rescue and Resuscitation
Was any attempt made to rescue the deceased?
Unknown
No
Yes (specify by whom)
What equipment was used to assist in the rescue?
Was any attempt made to resuscitation the deceased?
Unknown
No
Yes (specify by whom)
Was the person trained in resuscitation?
Unknown
No
Yes
Signage
Were there warning signs in the area where the death occurred?
N/A
No
Yes (specify)
Marine Animals
Was the death caused by a water animal (e.g. shark, crocodile, box jelly fish)?
N/A
Unknown
No
Yes (specify)
Swimming Pools / Spas / Dam / Pond
Was the pool/spa/dam/pond fenced?
No
Yes
If No, (the pool/spa/dam/pond was not fenced) were there any barriers between the pool/spa/dam/pond
and other structures (e.g. door, window locks)?
Unknown
No
Yes (specify)
If Yes, (the pool/spa/dam/pond was fenced) which diagram best presents fence installation
(S = structure e.g. house)
1
2
3
4
5
6
Other
If Other, describe fence or other barrier separating pool/spa/dam/pond from structure
Describe type of fence (e.g. height, material, horizontal bars)
Use the diagram, indicate the position of gate in reference to pool/spa/dam/pond
Top
Bottom
Left
Right
Was the gate defective
Unknown
No
Yes (describe defect)
Was gate self-latching
Unknown
No
Yes (describe defect)
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Was gate open or closed at the time of the incident
Unknown
Open
Closed
SECTION 16 – UNEXPECTED INFANT/CHILD DEATH
Ensure ‘sudden unexpected death in infancy’ checklist is completed and attached
Has a SUDI Checklist been completed
No
Yes
Scene
Where was the infant found
Infant’s Bedroom
Parent’s Bedroom
Other (specify)
Where was the infant sleeping alone?
Unknown
Yes
No (explain)
Position of infant when found
On Back
On Stomach
Head to right side
On Side
Head to left side
Head face down
Unknown
Were any items covering the infant’s head/face?
Unknown
No
Yes (specify)
Were there any signs of mechanical causes of strangulation or suffocation?
Unknown
No
Yes (specify)
Was there debris/object in the infant’s mouth?
Unknown
No
Yes (specify)
Medical Information
Was the infant born prematurely
Unknown
No
Yes (specify)
Did the infant have any of the following in the two weeks prior to the death?
Cold
Fever
Recent injury or other illness
Sniffles
Wheezing
Diarrhoea
Cough
Vomiting
Recent Inoculation
Was the child known to have any of the following
Abnormal Development
Recent Exposure to Contagious Disease
Medical Equipment in Use
Known Allergies
Recent Hospital Visit(s)
Any known medical problems
Has there been any other child die in the immediate family?
Unknown
No
Yes
If Yes, what was the cause of death?
Other Information (observations)
Were there any signs of habitual smoking in the household?
Unknown
No
Yes (describe)
Was there any evidence of alcohol or drug use around the infant?
Unknown
No
Yes (describe)
Is there any history of family violence?
Unknown
No
Yes (describe)
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

Please save this document prior to sending it as an ‘email’ by 7am to either:
Hobart > coroners.hobart@police.tas.gov.au
Launceston > coroners.launceston@police.tas.gov.au
Life Extinct Report etc. to be forwarded as per normal.
Police Report of Death for the Coroner > November 2011 (v.3)
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