Recommendations from the Coroner

From time to time, a state coroner may refer a finding of an inquest to Ahpra or the Board to bring to the attention of the profession. Ahpra will publish a case summary of each referral from the Coroner on its website, naming the deceased person, with the coroner’s recommendations in full. A link will also be provided to the coroner’s website. Practitioners are encouraged to access the Ahprawebsite at www.ahpra.gov.au to keep up to date with these cases and the coroner’s recommendations.

When the Board decides that a referral from the coroner has wide-reaching implications for practitioners, it may publish a summary of the case, and highlight particular issues relevant to the profession.

The following cases have been summarised for the education of all practitioners:

Details: Inquest into the Death of an adolescent (KP), the State Coroner of Victoria.
Board: Psychology Board of Australia 
Finding date: 5 April 2017
Summary of recommendations from the Coroner:  HTML – PDF (51.7 KB, PDF)  – Word version (571 KB,DOCX)

Details: Inquest into the Death of Caroline Emily Lovell by the Coroner’s Court of Victoria constituted by Peter White, Coroner.
Board: Nursing and Midwifery Board of Australia
Finding date: 24 March 2016
Summary of recommendations from the Coroner:  HTML – PDF (161 KB,PDF) – Word version (602 KB,DOC)

Full recommendation: See the Coroner’s Court of Victoria website.

Details: Inquest into the death of Summer Alice Steer by the Office of the State Coroner, Queensland Courts constituted by John Hutton, Coroner.
Board: Medical Board of Australia
Finding date: 3 November 2015
Summary of recommendations from the Coroner: HTML - PDF version (52.1 KB,PDF) - Word version (434 KB,DOC)

Full recommendation: See the Queensland Courts’ website.

Details: Inquest into the Death of Amber Sweetman by the State Coroners Court of South Australia constituted by Anthony Schapel Deputy State Coroner.
Board: Medical Board of Australia
Finding date: 26 March 2012
Recommendations from the Coroner: HTML -  PDF version (57.7 KB) - Word version (176 KB,DOC)

Full recommendation: See the Courts Administration of South Australia website.