Life Extinct Form I MR 41 . F (24 hour clock) M : No Sex: Time: ) Yes / / / ? / (Affix identification label here) label identification (Affix Date: Date: ...... Coroner’s Act 2003 Page 1 of 2 URN: Family name: Given name(s): Address: Date of birth: (please tick one below) (see over for definitions) (please print) (see over for definition*)

– see over for detaills*) Life Extinct Form Life Extinct ...... employed as a paramedic) of obvious death ’, under which category of reportable death: ’, under which category of reportable Death in care operations Death in custody or as a result of police Unknown person unnatural (including or trauma) Violent Happened in suspicious circumstances Death was healthcare related not likely to be issued (cause cause of death certificate unknown) A (A registered nurse, as defined in the Nursing Act Registered 1992 Nurse (A Act 1991 and paramedic, officr as defined an ambulance in the Ambulance Service Paramedic (A Act 1990) (only for cases Administration as defined in the Police Service police officer, Officer (A Police ) Act 2001 as defined in the Medical Practitioners Registration medical practitioner, Medical Practitioner (A No response to centralised stimuli Fixed dilated pupils No palpable carotid pulse No heart sounds heard for 30 seconds No breath sounds heard for 30 seconds

Coroner or Police Officer / Station notified of death: Coroner or Police Officer / Station and (please tick boxes below identifying clinical determination of death; all boxes must be ticked to certify death) (please tick boxes below identifying clinical determination of death; all boxes must be ticked or It must be documented in the person’s clinical record / transport notes that the death has occurred. clinical record / transport notes that in the person’s It must be documented person who is police to remove and transport a staff, funeral directors and This form allows mortuary deceased. I declare life to be extinct. I have completed the following assessments and there is: assessments I have completed the following This is an obvious death is an obvious This ALERTS

Facility:

If ‘Yes CERTIFYING PERSON DETAILS CERTIFYING PERSON DETAILS Location of examination: ’, state name of doctor issuing death certificate: If ‘No’, state name of doctor issuing death LIFE EXTINCT CERTIFICATION Is the death reportable to the Coroner under the Is the death reportable CORONER’S CASE This form is only completed when a Cause of Death Certificate is not likely to be issued expediently Certificate is not likely to be issued completed when a Cause of Death This form is only • When a cause of death certificate exists, a life extinct form is not required. death certificate exists, a life extinct When a cause of • Name: Position title: Signature:

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DO NOT WRITE IN THIS BINDING MARGIN , The or Act by a police s death if the person . Act. For more information Act. For more . or A failure to provide healthcare causes A Mental Health Act 2000 (“the MHA”); or Act 2000 (“the MHA”); Mental Health ). or or Page 2 of 2 may not need to be reported if identification can be achieved, Coroners Act 2003 Disability Services Act 1992 (“the DSA”); or Disability Services has caused extensive discolouration of the skin, bloating of the body or has exposed most of the skeleton, so called “skeletal remains”. , the following are reportable deaths to the Coroner. The local Coroner or the local or the local Coroner The local Coroner. to the deaths are reportable following , the has caused decapitation, severance of the torso, disruption of a vital organ (e.g. brain), has caused decapitation, severance of the torso, disruption of a vital organ are those where the state of the body is clearly incompatible with life: IF ANY DOUBT EXISTS THAT A PERSON IS DEAD, A DOUBT EXISTS THAT ANY IF and, in some cases, larval infestation and partial exposure of bones; Advanced decomposition It is not known who the personIt is not known is; or the death was or otherwise violent unnatural death; or fragmentation of the body; or established decomposition Well has caused charring and blackening of most of the body surface, with exposure of Severe incineration has caused charring and blackening of most of the body surface, with underlying tissues in some areas; Extensive trauma the death happened in suspicious circumstances; the death was a healthcare or related death; is has not been issued, and a cause of death certificate the person, not likely to be issued, for the death was in care; or a death the death was in custody; or a death the death occurred as a result of police operations. EMERGENCY RESUSCITATION ATTEMPTS SHOULD BE COMMENCED ATTEMPTS RESUSCITATION EMERGENCY • a) b) • • • “Custody is defined to mean detention under arrest or the authority of a court order or an “Custody is defined to mean detention actually in custody, trying to escape from custody or trying to avoid being put into custody. trying to escape from actually in custody, had a disability as defined in s5 of the had a disability as defined in s5 of officer or Corrective Services officer, court officers or other law enforcement personnel. officer or Corrective Services officer, was subject to involuntary assessment or treatment under the was subject to involuntary assessment guardianship of the Department of Child Safety was a child in the care or under the c) d) e) f) g) h) * Obvious death – where Queensland Police may issue Life Extinct Form * Obvious death – where Queensland Police may issue “Obvious deaths” would not have died at that time without the healthcare being provided. would not have died at that time without would not have died at that time if the healthcare had been provided. or contibutes to death if the person means a person qualified in the relevant area of healthcare who has reference to an independent person the clinically accepted range of risk and the state of health, regard to all relevant matters including the person’s circumstances in which healthcare was provided or sought. deaths (Section 10AA) Definition of healthcare related health procedure or any care, treatment or advice, service or goods provided “Healthcare” is defined to mean a or other human health. Health procedure means any dental, medical, surgical for or purportedly for the benefit of for example the administration of an anaesthetic, analgesic, sedative or health related procedure, including if (a) the healthcare caused or contributed to the death and immediately death is healthcare related A other drug. (b) an independent person would not have expected the death to occur; or before the healthcare was provided or contributed to the death and at the time the healthcare was sought a failure to provide healthcare caused expected that there would be a failure to provide healthcare that would an independent person would not have Healthcare causes or contibutes to a person’ cause or contribute to the death occurring. • (Section 10) Definition of death in custody those who are at the time of their death: The term is defined in s10 to include • These deaths can be conveniently classified into 3 categories depending on whether the person: depending on whether the be conveniently classified into 3 categories These deaths can • in care (Section 9) Definition of death Queensland Police station must be contacted to report the death under the Coroners under the Coroners to report the death must be contacted Police station Queensland to: www.justice.qld.gov.au/courts/coroner/home please go 8) (Section death categories Reportable • • and paramedics) may issue a Life In obvious deaths, police officers (as well as doctors, registered nurses category in which police officers may issue a Life Extinct Form. This is the ONLY Extinct Form. Coroner “Obvious deaths” associated with trauma or burns are reportable to the “Obvious deaths” associated with decomposition cause of death, and if the death is not if a doctor can issue a certificate (Form 9) with an opinion as to a natural otherwise reportable (see section 8 of the Coroners the Coroners Under Act 2003 Reportable Deaths to the Coroner to the Deaths Reportable