1. LYNDAL BUGEJA Keynote Presentation MANAGER CORONERS PREVENTION UNIT

2. The Medico-legal Investigation of Suicide Lyndal Bugeja Manager, Coroners Prevention Unit Coroners Court of Victoria

3. Outline The Coroner and the Coroners Court of Victoria Coroners’ Investigation – Initial Investigation – Forensic Medical and Scientific Investigation – Further Investigation – Coroners’ Findings Coroners’ Recommendations Coroners’ Investigation of Suicide

4. The Coroner Coroner first established in England 1194 as a source of revenue raising for the crown Preventative role first identified in 1316 after the death of a quarry worker Office of Coroner taken over by Justices of the Peace by 1500 with their role reduced to the investigation of sudden death and death registration Coroners system adopted in Australia at the time of settlement The first Victorian Act which referred to Coroners was the Coroners Statute 1865 Victoria has a centralised coronial system with 9 full time coroners Coroners must be legally trained with at least five years practicing experience

5. Coroners Court of Victoria Established as a specialist inquisitorial Court by the Coroners Act 2008 (Vic) The Act states what coroners must investigate and how this investigation should be conducted – Reportable deaths – Reviewable deaths – Fire without death

6. Reportable Deaths Section 3 of the Coroners Act 2008 (Vic) defines a reportable death as: – body in OR death occurred in OR usual resident of Victoria AND – death was unexpected, appears unnatural, violent, or result (directly or indirectly) of an accident or injury OR – during or following a medical procedure OR – identity is unknown OR – medical practitioner not signed a death certificate OR – death occurred in ‘care or custody’ or while under control or custody of the Secretary of the Dept of Justice or Victoria Police OR – death of a patient within the Mental Health Act 1986 (Vic) OR – death of a person subject to a non-custodial supervision order

7. Reviewable Deaths Section 5 of the Coroners Act 2008 (Vic) defines a reviewable death as: – death of a second or subsequent child (person < 18 years of age) of a parent EXCLUDES – stillborn children – children who lived their entire lives in hospital

8. Fires Without Death Section 30 of the Coroners Act 2008 (Vic) – Coroner must investigate a fire after receiving a request to investigate from Country Fire Authority Metropolitan Fire and Emergency Services Board – Unless Coroner determines it is not in the public interest

9. Coroners’ Investigation Initial Investigation Forensic Medical and Scientific Investigation Further Investigation Coroners’ Findings – Finding with inquest – Finding without inquest Coroners’ recommendations

10. Initial Investigation Case initiated at the Coronial Admissions and Enquiries Office (CAE) Duty Coroner confirms the death is “reportable” or “reviewable” (if required) Duty forensic pathologist – views the body – reviews the CT scan of the body – reviews medical information – reviews the circumstances – presents this information to the Coroner and a probable cause of death (where they can) Coroner determines the need for an autopsy

11. Forensic Medical & Scientific Investigation Led by a Forensic Pathologist Post-mortem examination – full autopsy – partial autopsy – external examination only Toxicology – all external cause deaths have full toxicology Histology Microbiology Entomology, Odontology, Anthropology Clinical Forensic Medicine

12. Further Investigation Led by Victoria Police as agent of the Coroner Gather information, including – statements from witnesses to the incident – statements from family, friends, other people known to the deceased – health care records – other relevant records – photographs, maps and other exhibits Coronial brief is provided to the Coroner

13. Coroners’ Finding With inquest Without inquest Must include – identity of the person who has died (if known) – the cause of death – Information needed to register the death – circumstances in which the death occurred if coroner deems it is in the public interest May include – comments – recommendations

14. Coroners’ Recommendations Public health and safety Administration of justice Responses to Coroners’ recommendations – public statutory authorities or entities must respond within three calendar months – ministers are not required to respond – Responses required must include a statement of what action has or will be taken – Responses must be published on the CCOV website

15. Coroners’ Investigation of Suicide Must be investigated Form the basis of mortality statistics Approximately 500-600 deaths in Victoria Coroners are not required to: – make a finding with circumstances – make a determination of the persons intent Efforts to strengthen the investigation of suicide – Suicide Investigation Standard – Suicide Finding Template – Proposed changes to the legislation to require Coroners to make findings with circumstances and determine intent – Victorian Suicide Register

16. Questions