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Occupational death investigation and prevention model for coroners and medical examiners
  1. Lyndal Bugeja1,2,
  2. Joseph Elias Ibrahim1,
  3. Lisa Brodie1
  1. 1Department of Forensic Medicine, Monash University, Victoria, Australia
  2. 2Accident Research Centre, Monash University, Victoria, Australia
  1. Correspondence to Lyndal Bugeja, Accident Research Centre, Building 70, Monash University, Clayton, Victoria 3800, Australia; lyndal.bugeja{at}

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In 2003, an estimated 345 719 fatal occupational injuries occurred worldwide.1 Occupational fatalities are largely preventable and are increasingly recognised as a major public health problem.2 The application of public health principles to death investigation potentially improves the capacity to prevent harm as it strengthens the understanding of injury determinants and prevention interventions.3

Internationally, investigations of occupational fatalities are conducted by coroners or medical examiners.4 5 The modern role of coroners or medical examiners includes the identification and promotion of prevention interventions.6 In Australia, deaths from injury are legally required to be reported to the coroner for investigation.7 The information generated for the coroner's investigation by the police and, in many circumstances, the occupational health and safety authority comprise the most comprehensive data source on occupational fatalities.8 On completion of the investigation, coroners must, when possible, make a finding reporting the deceased's identity and the cause and circumstances surrounding the death.7 Coroners also have the discretion to make recommendations on matters of public health and safety and the administration of justice.7

Recognised limitations of these investigations include: coroners' lack of knowledge or training in public health, policy development and injury prevention; the paucity of resources to identify or examine known risk and contributory factors comprehensively, evaluate system failures and the effectiveness of countermeasures; and the lack of time, expertise and resources required to consider the potential implications for similar workplaces comprehensively.8 As a result, injury determinants are not systematically identified from the investigation, limiting coroners' ability to make recommendations on injury prevention.

To overcome these limitations and strengthen occupational death and injury prevention via coroners' recommendations, an occupational death investigation and prevention team, the Work-Related Liaison Service (WRLS), was established at the Victorian Coronial Services Centre in Australia.

The WRLS developed …

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  • Funding The programme of work was undertaken by the Work-Related Liaison Service located at the Coronial Services Centre, funded by WorkSafe Victoria.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Victorian Institute of Forensic Medicine Ethics Committee.

  • Provenance and peer review Not commissioned; not externally peer reviewed.