Coroner Reports

Our reports analyse working systems and identify any shortcomings related to a death. 

Specifically, we will:

• Document any lapses in care leading up to the death.
• Assess flaws in working systems or the absence of systems that contributed to the death.
• Determine if reasonable precautions might have prevented the death.
• Identify ongoing risks related to any flaws or missed precautions.
• Include any additional relevant observations for the investigation.