NW Newborn Clinical Guideline - Coroner's referral form

Coronial Autopsy
Clinical Summary Form

Reviewed by Simon Rowley and Jane Harding

December
2000

Back to Guideline on Deaths in NICU

CORONIAL AUTOPSY – CLINICAL SUMMARY FORM

Notes

1. Form to be completed by treating Doctor and sent with body to Mortuary.

2. This is not a substitute for the medical notes which must also be forwarded to the Mortuary.

3. All IV lines, catheters, NG tubes etc to be left in-situ and not removed prior to autopsy.

4. If deceased is a child and is to be viewed by the parents before autopsy, tubes, lines etc can be cut short and covered with a dressing.

___________________________________________________________

Patient’s Full Name

Summary of History and Clinical Findings

(including any relevant investigation)

Summary of Operative Procedure and Findings (where applicable)

Specific Points to be Addressed

Suspected Cause of Death

Name and contact number of treating Doctor (and signature):

Coronial Autopsy Clinical Summary Form

Coronial Autopsy
Clinical Summary Form