Coronial Cases

All perinatal deaths reported to the NSW Coroner and referred to the Department of Forensic Medicine for post mortem examination must have the clinical scenario reviewed by a perinatal pathologist.

In some complex perinatal cases, this may include assistance from paediatric anatomical pathologists working in the non-Coronial system to review the case and help inform an inquest.  A protocol has been developed to outline referral criteria and referral procedure.

Referral protocol

Referral form (attach to referral email)

Reportable Deaths

A medical team must consult with the on-call Department of Forensic Medicine pathologist if they decide to report a perinatal death to the police as an inappropriate referral will cause unnecessary distress for grieving families.

The pathologist will work with the medical team to go through the Coroners Act referral indicators and provide advice on referral. 

NSW Police will outline their involvement and advise on how to preserve evidence and complete any documentation. 

They will also provide guidance on how to care for the deceased and how to best support the family.

Other resources
  • NSW Perinatal Post Mortem Service Reportable Death Scenario Guide 
  • NSW Health Policy: Perinatal Deaths and the NSW Coroners Act 2009
  • NSW Health Policy: NSW Health and the Coroners Act 2009
  • NSW Health Information Bulletin: NSW Health Coronial Checklist 
  • NSW Health Form: Report of a Death to the Coroner (SMR 010.510)
  • NSW Health Form: Coronial Checklist (SMR 010.513) 

Contact NSW Coroners Court or Coronial Information and Support Program, p. 02 8584 777

Investigating Stillbirth

The Perinatal Society of Australia and New Zealand Clinical Practice Guideline for Perinatal Mortality; Investigation of Stillbirths has recently been updated.  This standardises investigations using a non-selective approach and clearly identify the investigations to be undertaken (core investigations) and the investigations to be completed in specific clinical conditions (selective investigations).  

Find the guideline here and the NSW Perinatal Post Mortem Service quick reference guide here which will help clinicians using the guideline. 

Sudden and Unexplained Death in Infancy (SUDI)

Sudden and Unexplained Death in Infancy occurs when an infant is less than 12 months old and when the death was unexpected or sudden in nature. 

  • The NSW Ministry of Health Policy Document outlines the procedures for management of SUDI deaths by NSW Health facilities.

Contact NSW Coroners Court or Coronial Information and Support Program, p. 02 8584 777