Department of Human Services

Disability SA Bulletin 95 - DCSI Coronial Policy - what you need to know about reporting a client death

March 2016 -  Learn about the deaths that must be reported to the coronial liaison officer

The aim of the DCSI Coronial Policy is to ensure compliance with the Coroners Act 2003 and the effective management and monitoring of coronial matters of interest to the Department for Communities and Social Inclusion (DCSI). 

Each DCSI division providing or funding services directly to clients has a coronial liaison officer. This officer provides advice and help to divisional staff and non-government organisation (NGO) staff to respond to and monitor coronial matters in compliance with the DCSI Coronial Policy.

What do you need to know as a disability service provider?

A person must immediately notify the SA Police or the State Coroner of a death in accordance with the Coroners Act 2003 after becoming aware that it is, or may be, a reportable death. This notification is not necessary if the person believes on reasonable grounds that the death has already been reported. A police officer or doctor often will have notified the State Coroner of any death that may be a reportable death.

A death must be reported to the State Coroner where it has occurred:

  • unexpectedly, unusually or by a violent, unnatural or unknown cause
  • on a flight or voyage to South Australia
  • while in custody
  • during, as a result of or within 24 hours of certain surgical or invasive medical procedures, including the giving of an anaesthetic for the purpose of performing the procedure
  • within 24 hours of being discharged from a hospital or having sought emergency treatment at a hospital
  • while the deceased was a 'protected' person
  • while the deceased was under a custody or guardianship order under the Children's Protection Act 1993
  • while the deceased was a patient in an approved treatment centre under the Mental Health Act 2009
  • while the deceased was a resident of a licensed supported residential facility under the Supported Residential Facilities Act 1992
  • while the deceased was in a hospital or other facility being treated for drug addiction
  • during, as a result or within 24 hours of medical treatment to which consent had been given under Part 5 of the Guardianship and Administration Act 1993
  • that a cause of death has not been certified by a doctor.

Disability service providers must notify Disability SA of any death that occurs as soon as reasonably practical. The Disability SA Coronial Liaison Officer should be notified of a death assessed as reportable. Service providers should fulfil any critical client incident reporting requirements.

Disability service providers need to:

  • have clear instructions in place for staff
  • ensure their organisational guidelines are followed
  • have ongoing liaison with DCSI regarding the management and review of coronial matters
  • develop and implement improvement strategies in response to the coroner's findings and recommendations.

The Reporting a Death form lists and describes deaths that are reportable and relevant to DCSI.


Michelle Hosking, Disability SA Coronial Liaison Officer
Feedback and Incident Review team, Disability SA
Phone +618 8207 0490

Nicole Bourke, DCSI Coronial Officer
Client Systems, DCSI
Phone +618 8413 9033

Contact: Michelle Hosking

Phone: +618 8207 0490


Page last updated : 15 Apr 2018

State Government of South Australia © Copyright DHS .[sm v5.4.7.1]