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4.2.6 Notification of a child death by the State Coroner and exchange of information

Last Modified: 02-Aug-2018 Review Date: 02-Jan-2019



To guide child protection workers in relation to the methods and procedures by which information, notifications and reports are exchanged with the Office of the State Coroner (the Coroner).

Practice Requirements

  • Information exchanged between the Coroner and the Department of Communities should be through the senior practice development officer – Professional Practice Unit (SPDO).   
  • Any request for information on the death of a child by the Western Australia Police Service (WA Police) is also to be referred to the SPDO-MS.
  • Any request for information on the death of a child received by parents or persons acting on their behalf be referred to the Coroner's Coronial Counselling Service (08 9425 2900).
Process Maps
Not applicable


  • Information exchange
  • The notification process
  • Report requests
  • Responding to contact from family
  • Information exchange

    The Coroner’s Act (1996) enables the Coroner to obtain information from any source to assist in the investigation and determination of a person’s death. The Coroner will also notify the Department of the reportable death of any child under the age of 18 years.  A reportable death is defined under the Coroner’s Act (1996) and includes any child who is in the Chief Executive Officer's (CEO's) care at the time of his or her death. It also includes any child whose death “appears to have been unexpected, unnatural or violent, or to have resulted directly or indirectly from injury”.

    The Department in turn will provide information which may assist or have a bearing on the Coroner’s Inquiry.

    The Department may seek details about the circumstances of the death of a child where it is believed that these may indicate risk or harm to another child. Requests for such information, including post mortem information, should be made via the SPDO-MS, who will make the request to the manager at the Coroner. The request should include the reasons the information is being requested. The information is confidential and is only to be used for promoting the safety of children believed to be at risk.

    The SPDO-MS and the Coroner’s Counselling Service may discuss issues relating to a group of deaths or a specific child death before formal written notification is made. Such discussions may be needed to assist coronial investigating officers, WA Police and pathologists.

    Child protection workers should refer to the Reciprocal Child Protection Procedures – State Coroner of Western Australia (in related resources).


    The notification process

    Step 1 - A notification of a reportable death is forwarded from the Coroner’s Counselling Service to the SPDO–MS.

    Step 2 - The SPDO-MS instigates a search of the client record systems to determine the nature and extent of contact with the subject child and/or family. The search is conducted on the subject child, the parents and any significant others, such as siblings.

    Step 3 - The SPDO–MS will provide information of the Department's contact with the family to the Coroner and the WA Police (OIC Major Crime Unit).

    Step 4 - The SPDO-MS is responsible for notifying relevant Department staff of the death(s). The notification to Department staff provides details about the child, the child’s parents, the circumstances of death, the extent of our contacts and identifies any issues of significance for the child and/or family.

    Step 5 - The SPDO–MS will advise the Director General and relevant Executive Director State-wide and South East or Executive Director State-wide and South West of a notification from the Coroner on a Child Death Notification Originating form (Form 469) and log the notification. If the case is closed, the SPDO–MS will record the date of the child's death in Assist and Objective.

    Step 6 - The Child Death Notification Originating from the Coroner form (Form 469) is forwarded by facsimile or email to the district office for the attention of the child protection worker and/or duty officer, financial assistance officer, team leader and district director.

    Step 7 - The child protection worker and/or team leader must assess the information received in the Form 469 and determine further action, such as:

    • assessing the care and safety of remaining siblings, which may include making a determination as to whether an investigation is necessary
    • assessing supports/services that may be required, or 
    • the provision of financial or other assistance.

    Step 8 - The minimum action requested is that Department staff are aware of the death should the family seek financial or other types of assistance.  If the notification is in relation to an open case, child protection workers must record the date of death on our information systems.

    Step 9 - The child protection worker provides initial and follow-up information to the SPDO-MS, as requested.

    Step 10 - Should the Coroner or WA Police officers on behalf of the Coroner, need to make an after hours notification of death and/or require information, the Coroner will notify the Crisis Care Unit (CCU).

    The CCU will advise the relevant Executive Director who, together with Crisis Care staff, will ascertain the extent of our contact and advise the Director General.

    The Executive Director will advise other officers, such as the district director or Corporate Communications, as per standard critical incident requirements.


    Report requests

    The State Coroner is responsible for investigating the circumstances of a reportable death and to determine the cause of that person’s death. The Coroner obtains information through two processes:

    1. Coronial Inquiry - an inquiry occurs when the Coroner examines information to determine a person’s death, and 
    2. Coronial Inquest - an inquest occurs when the Coroner’s Court examines information to determine a person’s death or groups of deaths.

    Requests for a report on the Department's history of contact, including reasons for contact with a child and their family, may come from the Coroner as part of that office’s investigation into a death. It is also desired practice that the WA Police (Coronial Inquiry Section) assisting the Coroner request information on our involvement or contact with a child and their family via the SPDO-MS, or via the Coroner. The Coroner or WA Police Officer acting on behalf of the Coroner who has investigative responsibility, formally forwards the written report request to the SPDO-MS.

    Situations may arise where duty police officers attending a death scene or those with investigative responsibility may directly request information about a child and their family from Department staff.  Where this occurs, Department staff must refer the police officer and the request to the SPDO-MS.  This is more likely to occur in country regions which have few designated Coronial Police Officers. 

    Where a child was in the CEO's care at, or immediately before the time of death, the Coroner must hold an Inquest.

    Upon receipt of the request, the SPDO-MS determines the status of the request (that is, Inquiry or Inquest). If the matter is for Inquest, the SPDO-MS will liaise with General Counsel regarding whether or not the assistance of the State Solicitor’s Office needs to be sought.

    Under the Parliamentary Commissioner Amendment Act 2009 - Division 3A, 19A (3), an investigable death occurs if a child dies in any of the following circumstances:

    • in the two years before the date of the child’s death, the CEO had received information that raised concerns about the wellbeing of the child or a child relative of the child
    • in the two years before the date of the child’s death, the CEO, under section 32(1)of the Act had determined that action should be taken to safeguard or promote the wellbeing of the child or a child relative of the child
    • in the two years before the date of the child’s death, any of the actions listed in section 32(1) of the Act were undertaken in respect of the child or a child relative of the child
    • protection proceedings are pending in respect of the child or a child relative of the child, or
    • the child or a child relative of the child is in the CEO’s care. 

    If contacted directly by staff from the Ombudsman WA, staff members are required to assist with inquiries, including telephone and personal interviews.

    Please contact the SPDO-MS if you have any queries.


    Responding to contact from family

    The death of a child is a traumatic, painful and difficult time for a parent. Parents (particularly those whose child was in the CEO's care) may have many questions about the circumstances and causes of their child’s death. Staff are requested to refer all enquiries received from parents or persons acting on behalf of parents to the counselling staff at the Coroner. The Coronial Counselling Service has been established to facilitate communication between the next of kin and all other parties and provide counselling and support at this difficult time. The counselling service can be contacted on 08 9425 2900. 

    The  Coronial Counselling Service webpage has ‘Information for Families’ resource documents in English, Chinese, Farsi, Italian and Vietnamese.