Coronial Liaison Unit

The Coronial Liaison Unit (CLU) was established in 2005, and aims to improve communication between the Department of Health and the coronial system.

The CLU:

  • reviews all health related inquest findings
  • disseminates findings to appropriate stakeholders for information and/or to seek expert advice
  • provides advice back to the Chief Medical Officer on the implementation of coronial recommendations
  • coordinates, on a biannual basis, WA Health’s response to the State Coroner in relation to coronial recommendations
  • ensures non-inquested cases have been duly investigated under local health service mortality review processes where appropriate.

The coronial system

The coronial system, incorporating the Coroners Court (external site), has the power to investigate deaths reported under the  Coroners Act 1996 (external site). Reportable deaths can be investigated confidentially or via public inquest.

Confidential post mortem reports are routinely made available to relevant hospitals by the Office of the State Coroner (external site). In addition to this process, a confidential post mortem report may be made available to health services for quality improvement purposes upon request.

Reporting a death

The notification of a reportable death to the Coroner is a statutory obligation, and should be undertaken as soon as possible after a death occurs (maximum of 24 hours). A reportable death is defined in the Act.

The process is outlined on the death in hospital form, found in the guidelines for using the death in hospital form (below).

Please note: WA Police Coronial Investigation Unit (CIU) phone/fax numbers identified on the current death in hospital form have changed (see below).

To report a death to the Coroner, or to seek guidance about reportable deaths, healthcare workers must contact the appropriate police unit.

Metropolitan Perth

Between 7.00am and 2.00am contact:

WA Police Coronial Investigation Unit (CIU).
Phone: 9267 5700
Fax: 9267 5755 (to send the death in hospital form).

Note: Between 5.00pm and 2.00am callers to this number may hear a recorded message advising that the office is unattended, and to call back during office hours. This message is directed at the general public. Healthcare workers are advised not to hang up as their call will be attended.

Between 2:00am and 7:00am contact:

WA Police Operations Centre
Phone: 131 444
An on-call CIU officer will be notified.

Country WA

Contact the local police.

If further guidance is required, contact Office of the State Coroner (OSC)
Phone: 9425 2900 (business hours)
Mobile: 0419 904 478 (after 4:30pm and on weekends).

The OSC should only be contacted if the CIU (or local police) are unable to assist.

For further information on reportable deaths contact the Department’s Legal and Legislative Services.


Progress report for Health Related Coronial Recommendations

From Death We Learn

Educational tools

Annual reports

See previous versions of From Death We Learn.

More information

Patient Safety Surveillance Unit

Last reviewed: 11-03-2020
Produced by

Patient Safety Surveillance Unit