Form No: DCSI 141
/DCSI Reporting a Death
(Mandatory Form)Once completed, email this form to the Coronial Liaison Officer for your division (contact details available on page 4)
Client details
Family name: / Given name:Address:
Postcode:
Date of birth: / Date of death: / Age:
Court orders or Guardianship Board orders at time of death (dateand brief description):
Details of any existing Palliative Care Plans:
Entry date to DCSI (date of first service):
Incident details - please briefly describe the circumstances of the death:
Reportable Deaths
Upon becoming aware of a death, a staff member must immediately consider whether the death is a reportable deathunder the Coroners Act 2003.
The questions below are a guide to help determine whether a death is a reportable death. If the answer to any of the questions is, or could be, YES, tick the box. Tick as many boxes as are relevant.
Adeath in custody is a special instance of a reportable death.Deaths in custody must be reported immediately by phone to the Coroner’s Office only. All other reportable deaths must be reported immediately by phone to the Coroner’s Office or to SAPOL.
If in any doubt – either about whether the death is reportable or whether it has already been reported – the staff member or their delegate must report the death. Failure to report a reportable death is an offence.
Deaths in Custody: report the death to the Coroner’s Office only
Was the person detained under any Act or law, including any Act or law providing for home detention?
Was the person in the process of being apprehended or being held at any place by a person authorised to do so under any Act or law of the State or by a person authorised to do so under the law of any other jurisdiction?
Was the person evading apprehension by any authorised person?
Was the person escaping or attempting to escape from any place or authorised person?
Other Reportable Deaths: report the death to the Coroner’s Office or to SAPOL
Was the death unexpected, unnatural or unusual?
Was the death due to an accident, suicide, heat stroke, drowning, choking, or following an apparent improvement in general health?
Was the death in violent or suspicious circumstances?
Is there evidence of recent assault? Are there any factors surrounding the death seem inconsistent or difficult to explain?
Was the cause of death unknown?
If the cause of death is unknown, there will usually be no certificate as to cause of death.
Was the death within 24 hours of being discharged from hospital, or the person having sought emergency treatment at a hospital?
Was the death during or as a result, or within 24 hours, of a surgical, invasive medical or diagnostic procedure,including an anaesthetic for the purposes of conducting a procedure?
Was the person protected under the Guardianship and Administration Act 1993?
Peoplewith mental incapacitymay be protected through the appointment of a guardian for the protection of their personal wellbeing and/or through the appointment of an administrator,whomanages their estate. Check the ‘Legal Documents’ section of the client record.
Was the person protected under the Aged or Infirm Persons’ Property Act 1940?
Peoplewho by reason or age, illness, or impairment,are unable to manage their affairs or are liable to be subjected to undue influence regarding their estate, may be protected under this Act. Check the ‘Legal Documents’ section of the client record.
Was the person in the custody or or under the guardianship of the Minister under the Children’s Protection Act 1993?
Was the person a patient in an approved treatment centre under the Mental Health Act 1993?
Was the person a resident of a licensed supported residential facility under the Supported Residential Facilities Act 1992?
Was the person accommodated in a hospital or other treatment facility for the purposes of being treatedfor drug addiction?
Was the death during, as a result of, or within 24 hours of receiving medical treatment to which consent has been given under Part 5 of the Guardianship and Administration Act 1993?
People with a mental incapacity may not be able to consent to medical treatment. This law enables guardians, relatives and/or the Guardianship Board to provide that consent.
Was the cause of death not certified by a doctor?
Have you ticked any of the boxes above? No►This is not a reportable death. Followyour division’srelevant procedures for this incident
Yes►This is a reportable death. Report the death (unless it has already been reported by someone else) and follow your division’s critical incidentprocedures
Has someone else reported the death? NoYes
Report made by:Organisation/Service
Date: / Time:
Reporting to the Coroneror SAPOL
Coroner’s Office: Call (08) 8204 0618 (select option1) 24 hours a day.
SAPOL: Call 131 444 or, in the case of an emergency,call 000.
Report made to:Date: / Time:
DCSI staff memberreporting to the Coroner or SAPOL
Family name: / Given name:DCSI Unit and Division:
Position Title:
Telephone: / Fax:
Email:
DCSI Manager / Director
Name: / Telephone:Title: / Mobile: / (if available)
Note: Please insert details of your line manager; this form may form part of future briefings.
If you have any questions about filling out this form, please raise them with your manager/supervisor, your division’s Coronial Liaison Officer or the DCSI Coronial Officer.
More information about reportable deaths and the Coronial system can be found in the DCSI Coronial Guidelines and Mandatory Procedures and DCSI Coronial Policy.
DCSI Coronial Liaison Officers
Disability Services Coronial Liaison OfficerGail Bennett / Ph:8272 1988 x 317
Fax:8372 1429
Email:
Domiciliary Care Coronial Liaison Officer
Jo Shirlock / Ph: 8132 6022
Fax: 8193 1256
Email:
Disability SA Coronial Liaison Officer
Michelle Hosking / Ph: 8207 0490
Fax: 8415 4233
Email:
Housing SA Coronial Liaison Officer
Wendy Hackel / Ph: 8207 0315
Fax:8207 0199
Email:
Youth Justice, Community Engagement and Organisational Support (Community Connect) Coronial Liaison Officer
Isabel Fforde / Ph: 8226 6901
Fax: 8226 7047
Email:
Youth Justice, Community Engagement and Organisational Support (Youth Justice) Coronial Liaison Officer
Katherine Hawkins / Ph:8207 0352
Fax:
Email:
Policy and Community Development Coronial Liaison Officer
Jacqueline Costanzo / Ph: 8207 0251
Fax:
Email:
Care Concern Investigations Coronial Liaison Officer
Rohan Crawford / Ph: 8207 0229
Fax: 820 70618
Email:
DCSI Coronial Officer
Nicole Bourke / Ph: 841 39033
Fax: 841 38143
Email:
March 2016
Sensitive: Legal
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