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The purposes of this Act are—
to require the reporting of certain deaths; and
to provide for coroners to investigate deaths and fires in specified circumstances; and
to contribute to the reduction of the number of preventable deaths and fires through the findings of the investigation of deaths and fires, and the making of recommendations, by coroners; and
to establish the Coroners Court of Victoria as a specialist inquisitorial court; and
to establish the Coronial Council of Victoria; and
S. 1(f) repealed by No. 34/2024 s. 45.
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to make consequential amendments to other Acts.
This Act comes into operation on 1 November 2009.
In this Act—
S. 3(1) def. of Aboriginal ancestral remains inserted by No. 11/2016 s. 138.
Aboriginal ancestral remains has the same meaning as in the Aboriginal Heritage Act 2006;
S. 3(1) def. of Aboriginal Heritage Council inserted by No. 11/2016 s. 138.
Aboriginal Heritage Council means the Council within the meaning of the Aboriginal Heritage Act 2006;
S. 3(1) def. of Australian lawyer repealed by No. 17/2014 s. 160(Sch. 2 item 21.1).
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autopsy means—
the dissection of a body (including the removal of tissue); or
any other prescribed procedure in relation to a body—
but does not include—
a preliminary examination; or
an identification procedure;
body means—
the corpse of a human being; or
a part or parts of the corpse or remains of a human being—
but does not include tissue removed from the corpse of a human being;
S. 3(1) def. of Chief Commis-sioner of Police inserted by No. 26/2023 s. 12.
Chief Commissioner of Police means the Chief Commissioner of Police appointed under section 17 of the Victoria Police Act 2013;
child means a person under the age of 18 years;
S. 3(1) def. of coroner amended by Nos 5/2013 s. 57(1), 63/2013 ss 49(a)(b), 82.
coroner means—
the State Coroner, including a person acting under section 12H of the County Court Act 1958;
the Deputy State Coroner;
a magistrate or reserve magistrate engaged under section 9C of the Magistrates' Court Act 1989 assigned to be a coroner of the Coroners Court under section 93;
a person appointed as a coroner of the Coroners Court under section 94;
a reserve coroner who is engaged under section 102N to perform the duties of a coroner during any period of engagement or acting under section 102S;
Coroners Court means the Coroners Court of Victoria;
S. 3(1) def. of coronial investigator inserted by No. 26/2023 s. 12.
coronial investigator means a police officer who is nominated by the Chief Commissioner of Police to assist a coroner in relation to an investigation into a reportable death;
Council means the Coronial Council of Victoria established under Part 9;
Country Fire Authority means the Country Fire Authority established under the Country Fire Authority Act 1958;
death includes suspected death;
Notes
1 A still-birth, within the meaning of the Births, Deaths and Marriages Registration Act 1996, is not a death.
2 See section 41 of the Human Tissue Act 1982 for a definition of death for the purposes of the law of Victoria.
Deputy State Coroner means the Deputy State Coroner of the Coroners Court appointed under section 92;
domestic partner of a person means—
a person who is in a registered relationship with the person; or
an adult person to whom the person is not married but with whom the person is in a relationship as a couple where one or each of them provides personal or financial commitment and support of a domestic nature for the material benefit of the other, irrespective of their genders and whether or not they are living under the same roof, but does not include a person who provides domestic support and personal care to the person—
for fee or reward; or
(ii) on behalf of another person or an organisation (including a government or government agency, a body corporate or a charitable or benevolent organisation);
S. 3(1) def. of Fire Rescue Victoria inserted by No. 20/2019 s. 149(2).
Fire Rescue Victoria means Fire Rescue Victoria established under the Fire Rescue Victoria Act 1958;
identification direction means a direction given by a coroner under section 24;
identification procedure means any procedure performed in accordance with an identification direction;
immediate family in relation to a deceased person, means spouse, domestic partner, son, daughter, parent, sibling, executor, personal representative or a person determined to be the senior next of kin under subsection (3);
inquest means a public inquiry that is held by the Coroners Court in respect of a death or a fire;
S. 3(1) def. of Institute amended by No. 34/2024 s. 46.
Institute means the Victorian Institute of Forensic Medicine established under the Victorian Institute of Forensic Medicine Act 2024;
interstate coroner means a coroner of another State or Territory;
interested party in relation to an inquest, means a person granted leave under section 56 to appear at the inquest;
S. 3(1) def. of judicial registrar inserted by No. 34/2010 s. 41.
judicial registrar means a judicial registrar of the Coroners Court appointed under Division 1A of Part 8;
medical examination means a preliminary examination, an identification procedure or an autopsy;
medical investigator means—
the Institute; or
a pathologist; or
a registered medical practitioner under the general supervision of a pathologist;
medical procedure means a procedure performed on a person by or under the general supervision of a registered medical practitioner and includes imaging, internal examination and surgical procedure;
S. 3(1) def. of Metropolitan Fire and Emergency Services Board repealed by No. 20/2019 s. 149(1).
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parent, in relation to a child, includes—
a step-parent;
an adoptive parent;
a foster parent;
a guardian;
a person who has custody or daily care and control;
a person who has all the duties, powers, responsibilities and authority (whether conferred by a court or otherwise) which, by law, parents have in relation to children;
pathologist means a prescribed registered medical practitioner;
S. 3(1) def. of person placed in custody or care amended by Nos 29/2010 s. 51(a), 43/2010 s. 44, 29/2011 s. 3(Sch. 1 item 18.1), 52/2013 s. 80, 26/2014 s. 455(Sch. item 5.1), 37/2014 s. 10(Sch. item 30.1(b)), 61/2014 s. 165, 39/2022 s. 799.
person placed in custody or care means—
a person for whom the Secretary to the Department of Human Services has parental responsibility under the Children, Youth and Families Act 2005; or
a child placed in emergency care under the Children, Youth and Families Act 2005; or
a person who is deemed to be in the legal custody of the Secretary to the Department of Human Services under section 483 of the Children, Youth and Families Act 2005; or
a person under the control, care or custody of the Secretary to the Department of Human Services or the Secretary to the Department of Health; or
a person in the legal custody of the Secretary to the Department of Justice or the Chief Commissioner of Police; or
a person in the custody of a police officer; or
a person in the custody of a protective services officer; or
a person detained in a treatment centre under a detention and treatment order made under section 20 of the Severe Substance Dependence Treatment Act 2010;
a patient detained in a designated mental health service within the meaning of the Mental Health and Wellbeing Act 2022; or
a person who a police officer or prison officer is attempting to take into custody or who is dying from injuries sustained when a police officer or prison officer attempted to take the person into custody; or
a person in Victoria who is dying from an injury incurred while in the custody of the State; or
a prescribed person or a person belonging to a prescribed class of person;
S. 3(1) def. of police officer inserted by No. 37/2014 s. 10(Sch. item 30.1(a)).
police officer has the same meaning as in the Victoria Police Act 2013;
preliminary examination in relation to a body means any of the following procedures—
a visual examination of the body (including a dental examination);
the collection and review of information, including personal and health information relating to the deceased person or the death of the person;
the taking of samples of bodily fluid including blood, urine, saliva and mucus samples from the body (which may require an incision to be made) and the testing of those samples;
the imaging of the body including the use of computed tomography (CT scan), magnetic resonance imaging (MRI scan), x-rays, ultrasound and photography;
the taking of samples from the surface of the body including swabs from wounds and inner cheek, hair samples and samples from under fingernails and from the skin and the testing of those samples;
the fingerprinting of the body;
any other procedure that is not a dissection, the removal of tissue or prescribed to be an autopsy;
prescribed means prescribed by the regulations unless otherwise provided;
principal registrar means the principal registrar appointed under section 97;
S. 3(1) def. of protective services officer inserted by No. 37/2014 s. 10(Sch. item 30.1(a)).
protective services officer has the same meaning as in the Victoria Police Act 2013;
S. 3(1) def. of registered medical practitioner substituted by No. 13/2010 s. 51(Sch. item 15).
registered medical practitioner means a person registered under the Health Practitioner Regulation National Law to practise in the medical profession (other than as a student);
registrar means the principal registrar, a deputy registrar or a registrar referred to in section 97;
reportable death has the meaning given by section 4;
S. 3(1) def. of reserve coroner inserted by No. 63/2013 s. 49(c).
reserve coroner means a person appointed under section 102L;
S. 3(1) def. of reserve judge inserted by No. 5/2013 s. 57(2).
reserve judge has the same meaning as it has in the County Court Act 1958;
S. 3(1) def. of reserve magistrate inserted by No. 5/2013 s. 57(2).
reserve magistrate has the same meaning as it has in the Magistrates' Court Act 1989;
reviewable death has the meaning given by section 5;
S. 3(1) def. of Secretary to the Department of Health inserted by No. 29/2010 s. 51(b).
Secretary to the Department of Health means the Department Head (within the meaning of the Public Administration Act 2004) of the Department of Health;
S. 3(1) def. of senior next of kin amended by No. 29/2011 s. 3(Sch. 1 item 18.2).
senior next of kin in relation to a deceased person, means—
if the person, immediately before death had a spouse or domestic partner—the spouse or domestic partner; or
if the person immediately before death did not have a spouse or domestic partner or if the spouse or domestic partner is not available—a son or daughter of or over the age of 18 years; or
if a spouse, domestic partner, son or daughter is not available—a parent; or
if a spouse, domestic partner, son, daughter or parent is not available—a sibling who is of or over the age of 18 years; or
if a spouse, domestic partner, son, daughter, parent or sibling is not available—a person named in the will as an executor; or
if a spouse, domestic partner, son, daughter, parent, sibling or executor is not available—a person who, immediately before the death, was a personal representative of the deceased;
if a spouse, domestic partner, son, daughter, parent, sibling, executor or personal representative is not available—a person determined to be the senior next of kin under subsection (3);
sibling in relation to a person includes a half‑brother, half-sister, adoptive brother, adoptive sister, step-brother or step-sister of the person;
spouse of a person means a person to whom that person is married;
State Coroner means the State Coroner of the Coroners Court appointed under section 91;
the rules means rules of the Coroners Court;
S. 3(1) def. of tissue amended by No. 19/2017 s. 42(1).
tissue has the same meaning as in the Human Tissue Act 1982;
S. 3(1) def. of VSRFVD inserted by No. 19/2017 s. 42(2).
VSRFVD means the Victorian Systemic Review of Family Violence Deaths unit established under section 102U.
For the purposes of the definition of domestic partner in subsection (1)—
registered relationship has the same meaning as in the Relationships Act 2008; and
in determining whether persons who are not in a registered relationship are domestic partners of each other, all the circumstances of their relationship are to be taken into account, including any one or more of the matters referred to in section 35(2) of the Relationships Act 2008 as may be relevant in a particular case; and
a person is not a domestic partner of another person only because they are co-tenants.
For the purposes of paragraph (g) of the definition of senior next of kin, a person is the senior next of kin if the coroner determines that the person should be taken to be the senior next of kin because of the closeness of the person's relationship with the deceased person immediately before his or her death.
In this Act—
a reference to a function includes a reference to a power and a duty; and
a reference to the exercise of a function includes, where the function is a duty, a reference to the performance of the duty.
In this Act, a death of a person is a reportable death if—
the body is in Victoria; or
the death occurred in Victoria; or
the cause of the death occurred in Victoria; or
the person ordinarily resided in Victoria at the time of death—
and the death was a death specified in subsection (2).
S. 4(1A) inserted by No. 48/2018 s. 5.
If a determination is made under section 16(1A), that death is not a reportable death for the purposes of this Act on and from that determination.
For the purposes of subsection (1), the deaths are—
a death that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; or
a death that occurs—
during a medical procedure; or
following a medical procedure where the death is or may be causally related to the medical procedure—
and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death; or
the death of a person who immediately before death was a person placed in custody or care; or
S. 4(2)(d) amended by Nos 26/2014 s. 455(Sch. item 5.2), 39/2022 s. 800.
the death of a person who immediately before death was a patient within the meaning of the Mental Health and Wellbeing Act 2022; or
S. 4(2)(e) amended by No. 37/2014 s. 10(Sch. item 30.2).
the death of a person under the control, care or custody of the Secretary to the Department of Justice or a police officer; or
S. 4(2)(f) amended by No. 55/2014 s. 143.
the death of a person who is subject to a non‑custodial supervision order under section 26 or 38ZH of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or
the death of a person whose identity is unknown; or
a death that occurs in Victoria if a notice under section 37(1) of the Births, Deaths and Marriages Registration Act 1996 has not been signed and is not likely to be signed; or
a death that occurs at a place outside Victoria if the cause of death is not certified by a person who, under the law in force in that place, is authorised to certify that death and the cause of death is not likely to be certified by a person who is authorised to certify in that place; or
a death—
of a prescribed class of person;
that occurs in prescribed circumstances.
S. 4(3) inserted by No. 61/2017 s. 121.
Despite subsection (2), the death of a person who has been administered or self‑administered a voluntary assisted dying substance within the meaning of the Voluntary Assisted Dying Act 2017 in accordance with that Act is not a reportable death.
Note
1. Section 14 includes a power for a coroner to investigate whether or not a death is a reportable death. If the death of a person is or may be due to the self-administration or administration of a voluntary assisted dying substance within the meaning of the Voluntary Assisted Dying Act 2017 other than in accordance with that Act, the coroner could investigate the death under section 14.
2. Section 52(1) provides for a coroner to hold an inquest into any death that the coroner is investigating.
In this Act, the death of a child (the deceased child) is a reviewable death if the deceased child is the second or subsequent child of the deceased child's parent to have died and one of the following applies—
the body is in Victoria; or
the death occurred in Victoria; or
the cause of the death occurred in Victoria; or
the child ordinarily resided in Victoria at the time of death.
Despite subsection (1), a death of a deceased child is not a reviewable death if—
the death occurs in a hospital; and
the child was born at a hospital and had always been an in-patient of a hospital; and
the death is not a reportable death.
In this section—
hospital means a public hospital, a public health service, a denominational hospital or a private hospital within the meaning of the Health Services Act 1988;
in-patient of a hospital includes a child whose only period spent outside a hospital was during a transfer from one hospital to another, by whatever means.
The objectives in this Part are intended to give guidance in the administration and interpretation of this Act.
It is the intention of Parliament that a coroner should liaise with other investigative authorities, official bodies or statutory officers—
to avoid unnecessary duplication of inquiries and investigations; and
to expedite the investigation of deaths and fires.
S. 8 amended by No. 34/2010 s. 6(a).
When exercising a function under this Act, a person should have regard, as far as possible in the circumstances, to the following—
that the death of a family member, friend or community member is distressing and distressed persons may require referral for professional support or other support;
that unnecessarily lengthy or protracted coronial investigations may exacerbate the distress of family, friends and others affected by the death;
that different cultures have different beliefs and practices surrounding death that should, where appropriate, be respected;
that family members affected by a death being investigated should, where appropriate, be kept informed of the particulars and progress of the investigation;
that there is a need to balance the public interest in protecting a living or deceased person's personal or health information with the public interest in the legitimate use of that information;
the desirability of promoting public health and safety and the administration of justice.
The coronial system should operate in a fair and efficient manner.
S. 10(1) amended by No. 31/2013 s. 12(1).
Subject to subsection (2), a registered medical practitioner who is present at or after the death of a person must report the death without delay to a coroner or the Institute if the death is a reportable death.
- 20 penalty units.
S. 10(2) amended by No. 31/2013 s. 12(1).
If more than one registered medical practitioner is present at or after a death and one of them reports it to a coroner or the Institute, the other practitioners need not report the death.
S. 10(3) inserted by No. 31/2013 s. 12(2).
The Institute must refer to a coroner a report of a reportable death received from a registered medical practitioner under subsection (1) or (2) as soon as practicable after receipt of that report.
S. 11(1) amended by No. 31/2013 s. 13(1).
The responsible person must report the death of a person placed in custody or care without delay to a coroner or the Institute.
- 20 penalty units.
S. 11(1A) inserted by No. 31/2013 s. 13(2).
The Institute must refer to a coroner a report of the death of a person placed in custody or care received from a responsible person under subsection (1) as soon as practicable after receipt of that report.
In this section, responsible person means—
in relation to a person referred to in paragraphs (a) to (i) of the definition of person placed in custody or care in section 3(1), the person who has care, control or custody of the person;
S. 11(2)(b) amended by No. 37/2014 s. 10(Sch. item 30.3).
in relation to a person referred to in paragraph (j) of the definition of person placed in custody or care in section 3(1), the police officer or the prison officer who attempted to take the person into custody;
in relation to a person referred to in paragraph (k) or (l) of the definition of person placed in custody or care in section 3(1), a person prescribed as the responsible person.
S. 12(1) amended by Nos 31/2013 s. 14(1), 37/2014 s. 10(Sch. item 30.4).
A person who has reasonable grounds to believe that a reportable death has not been reported must report it without delay to a coroner, the Institute or the police officer in charge of a police station.
- 20 penalty units.
S. 12(2) amended by Nos 31/2013 s. 14(2), 26/2014 s. 455(Sch. item 5.3), 39/2022 s. 801.
A member of the immediate family of a deceased person may report the death to the coroner or the Institute if the person was a person discharged from a designated mental health service within the meaning of the Mental Health and Wellbeing Act 2022 within 3 months immediately before the person's death.
S. 12(3) inserted by No. 31/2013 s. 14(3).
The Institute must refer to a coroner a report of a death received under subsection (1) or (2) as soon as practicable after receipt of that report.