Form 3 "Doctor's Notice to Coroner After Autopsy" - Queensland, Australia

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Printed case
Form 3, Version 5
number,
name and
QUEENSLAND CORONERS ACT 2003
(Section 24)
barcode on
sticker
DOCTOR’S NOTICE TO CORONER AFTER AUTOPSY
SECTION A – to be completed by the doctor who has performed the autopsy immediately following autopsy
1. To the coroner at:
(print place)
________________________________________________________________
(print name of deceased person)
whose date of birth was _____________
underwent an autopsy on _______________
(print date of birth)
(print date of autopsy examination)
in the mortuary at
In accordance with an order for autopsy
(print place autopsy conducted).
dated_______________
I performed the following type of examination
(tick one box only)
(print date of autopsy order),
External examination only
External and full internal examination
Examination of the cremated remains
External and partial internal examination: ________________________________________
(insert details eg: chest only)
2. Does the pathologist wish to retain prescribed tissue?
(please tick)
Note: “Prescribed tissue” means whole organs, identifiable body parts, and a foetus removed from a pregnant woman, see State Coroner’s Guidelines.
Yes: already authorised by coroner: please confirm details in sections 3 and 4
Yes: coroner’s decision is now sought: please provide details in sections 3 and 4
No: go straight to section 5
3. Prescribed tissue pathologist wishes to be retained for testing, examination or evidence:
Please tick or specify the tissue sought and type of testing, etc intended
Portion of bone:
Brain / Spinal cord for neuropathology
other ________________
spine
skull
rib
Whole heart for detailed cardiac pathology
For:
examination
tool mark analysis
evidence
Whole lung for volatiles toxicology (glue etc)
_______________________________________________________
(specify)
_______________________________________________________
One / both eyes for dissection and histology
(specify)
4. Summary of reasons why retention of prescribed tissue is necessary for the investigation of the death:
5. Non-prescribed tissue kept for testing or evidentiary purposes:
Note: “Tissue” includes blood and body fluids. “Non-prescribed tissue” refers to tissue other than whole organs, foetuses or identifiable body parts.
Non-prescribed sample/tissue kept
Tests Arranged
Ordered by Coroner
Please tick or specify as needed
Please tick
Please tick
Tissues in formalin: cassettes / wet tissue (
)
Histology
Yes
No
please circle
Blood, urine, vitreous, stomach contents, liver, hair, body cavity fluid
Toxicology:
rapid
limited
Yes
No
_________________________________________________
(specify)
full
hold only
Samples for infant death: skin, heart, liver, trachea, lung, metabolic
Cytogenetics, microbiology &
No
Guthrie card, skeletal muscle, blood
metabolic studies, etc
FTA card for DNA (plus other samples if needed)
Forensic DNA Analysis
No
Other:
Form 3 Version 5 – 6 April 2021
1
Printed case
Form 3, Version 5
number,
name and
QUEENSLAND CORONERS ACT 2003
(Section 24)
barcode on
sticker
DOCTOR’S NOTICE TO CORONER AFTER AUTOPSY
SECTION A – to be completed by the doctor who has performed the autopsy immediately following autopsy
1. To the coroner at:
(print place)
________________________________________________________________
(print name of deceased person)
whose date of birth was _____________
underwent an autopsy on _______________
(print date of birth)
(print date of autopsy examination)
in the mortuary at
In accordance with an order for autopsy
(print place autopsy conducted).
dated_______________
I performed the following type of examination
(tick one box only)
(print date of autopsy order),
External examination only
External and full internal examination
Examination of the cremated remains
External and partial internal examination: ________________________________________
(insert details eg: chest only)
2. Does the pathologist wish to retain prescribed tissue?
(please tick)
Note: “Prescribed tissue” means whole organs, identifiable body parts, and a foetus removed from a pregnant woman, see State Coroner’s Guidelines.
Yes: already authorised by coroner: please confirm details in sections 3 and 4
Yes: coroner’s decision is now sought: please provide details in sections 3 and 4
No: go straight to section 5
3. Prescribed tissue pathologist wishes to be retained for testing, examination or evidence:
Please tick or specify the tissue sought and type of testing, etc intended
Portion of bone:
Brain / Spinal cord for neuropathology
other ________________
spine
skull
rib
Whole heart for detailed cardiac pathology
For:
examination
tool mark analysis
evidence
Whole lung for volatiles toxicology (glue etc)
_______________________________________________________
(specify)
_______________________________________________________
One / both eyes for dissection and histology
(specify)
4. Summary of reasons why retention of prescribed tissue is necessary for the investigation of the death:
5. Non-prescribed tissue kept for testing or evidentiary purposes:
Note: “Tissue” includes blood and body fluids. “Non-prescribed tissue” refers to tissue other than whole organs, foetuses or identifiable body parts.
Non-prescribed sample/tissue kept
Tests Arranged
Ordered by Coroner
Please tick or specify as needed
Please tick
Please tick
Tissues in formalin: cassettes / wet tissue (
)
Histology
Yes
No
please circle
Blood, urine, vitreous, stomach contents, liver, hair, body cavity fluid
Toxicology:
rapid
limited
Yes
No
_________________________________________________
(specify)
full
hold only
Samples for infant death: skin, heart, liver, trachea, lung, metabolic
Cytogenetics, microbiology &
No
Guthrie card, skeletal muscle, blood
metabolic studies, etc
FTA card for DNA (plus other samples if needed)
Forensic DNA Analysis
No
Other:
Form 3 Version 5 – 6 April 2021
1
Printed case
number,
name and
6. Cremation Risks (pacemakers, radioactive implants, or other implanted devices):
(please tick one of the following
barcode on
sticker
To the best of my knowledge and belief, based on my examination of the deceased, there are no pacemakers or other
implanted devices that would pose a cremation risk.
I found in the course of my examination a ____________________________________________________________
and removed this device. To the best of my knowledge and belief, there is no further cremation risk.
I am unable to advise whether any pacemakers or other implanted devices that would pose a cremation risk are present.
7. Infection Risk:
(please tick one of the following)
The deceased is not known or suspected to be suffering from any infectious disease that presents a risk to those
transporting the body if transported and handled using standard infection control measures.
The deceased may present an infection risk. Further advice should be sought as to the infection control measures required.
I am unable to advise about infection risk as there is insufficient information. Standard infection control must be used.
8. Cause of Death:
(please tick one of the following)
I have completed an autopsy certificate (Form 30)
I have completed an autopsy notice (Form 29)
I have not completed either because the deceased is not identified.
9. Is the body ready for release?
(please tick or give details below as necessary)
Is tissue donation (if any)
Yes
No: but will be within 24 hours
Not applicable
complete?
Is examination of the body
Yes
No: but will be within 24-48 hours
Other: details below
complete?
Is all prescribed tissue returned
Yes
No: but will be within 24-48 hours
Other: details below
to body?
Is the body formally identified,
Yes
No: but likely within 24-48 hours: Form
Dental ID, DNA, etc needed as
as per Police Report (Form 1 or
29/30 will be issued when ID confirmed
detailed below: coroner can release
Supplementary Form 1)?
by police (Supplementary Form 1)
once satisfied about ID
Details:
10. Summary of pathologist’s main macroscopic autopsy findings (positive and negative) and any other comments:
11. I recommend that reports/statements be obtained from:
(please tick whichever apply and give details)
Medical records
Treating doctors
nurses
paramedics
(if not already arranged via Form 5)
Medical specialist
Other __________________________________________________
(note relevant speciality)
in relation to the following issues:
Doctor's signature:
Date:
Doctor’s name:
(print name)
Office telephone no:
Mobile no:
Fax:
Form 3 Version 5 – 6 April 2021
2
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