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Explanatory Notes

//Explanatory Notes
Explanatory Notes 2018-09-19T03:58:34+00:00

The National Coronial Information System (NCIS) is a data repository for the collection, storage and access of coronial data. Data is provided to the NCIS by all coronial jurisdictions in Australia and New Zealand.  The following explanatory notes are designed to provide information about the collection, organisation and interpretation of NCIS data.

Data stored in the NCIS assists coroners, death investigators, public sector agencies, researchers and community groups in obtaining evidence to identify mortality trends and risk factors, and to inform death and injury prevention initiatives and policy development.

Reportable Death

All Australian and New Zealand coronial jurisdictions investigate deaths in accordance with their respective Coroners Act. Each Act defines what constitutes a ‘reportable death’ to determine which deaths must be investigated by a Coroner. The definition of a ‘reportable death’ may vary between jurisdictions and it is therefore not always possible to compare frequencies of certain types of deaths between jurisdictions. No conclusions can be drawn from comparing frequencies between jurisdictions without consideration of the definition of a ‘reportable death’ for the type of death of interest. In addition, the interpretation of a ‘reportable death’ according to the Act is at the discretion of the relevant State or Chief Coroner and may change over time.

Data Sources

Coronial Data

The data contained in the NCIS is sourced from the coronial brief created as part of the investigation conducted by a Coroner into the death of an individual. The purpose of the investigation is to determine the identity of the deceased and the cause of death. Data is sourced from all coronial jurisdictions in Australia and New Zealand about all reportable deaths. Data contained in the NCIS is collected as part of an investigative process and not a data collection process. Therefore, the information contained in the NCIS reflects the level of detail obtained through the investigation and the comprehensiveness of data collection can vary.

As far as possible the data is nationally standardised. The NCIS Data Dictionary contains a detailed list of the NCIS Codeset and how it is applied.

Supplementary Data

Supplementary data is provided by the Australian Bureau of Statistics (ABS), the New Zealand Ministry of Health (MoH) and Safe Work Australia.

  • Causes of Death Australia: International Classification of Diseases, Tenth Revision (ICD-10) codes – ABS
  • Causes of Death New Zealand: International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes – MoH
  • Worker related codes including occupation, industry, and injury type (TOOCS 3.0) – Safe Work Australia

At present there is no equivalent Work Cover data sourced for New Zealand Cases.

All supplementary data is updated annually.

Reference Period

Data collection for all Australian States and Territories commenced on 1 July 2000, with the exception of Queensland which commenced on 1 January 2001. The collection of New Zealand data commenced on 1 July 2007.

Scope And Coverage

The NCIS contains data about fatalities reported to and investigated by a Coroner in Australia and New Zealand within the reference period. This means that not all fatalities are contained in the NCIS. Deaths reported directly to Registries of Births, Deaths and Marriages are excluded as the NCIS only contains coronial data. Cases where the Coroner begins an investigation but then determines that the case does not to constitute a reportable death are removed from the NCIS.

Data entered into the NCIS is collected from source material such as the police notification of death report, autopsy reports, toxicology reports and coronial findings from the nine Australian and New Zealand jurisdictions. It is acknowledged that the level of detail contained in these documents may vary between and within each jurisdiction. There are also differences in the coronial legislation in each jurisdiction which governs the reporting of a death to a Coroner. Legislative differences can impact on the type and quantity of the information collected and reported by each jurisdiction. These differences will have an impact on the information available in the NCIS.

Data contained on the NCIS is the result of an investigative process, not a data collection process. Contributing data to the NCIS is not the primary purpose of the investigation and while every effort is made by the NCIS to achieve consistent, comprehensive data collection, there are known limitations.

This data set does not purport to be representative of every relevant death within the time period specified. Due to occasional processing and coding errors, missing data, and cases still under investigation, it is possible this data set may be incomplete or contain inaccuracies.

The NCIS does not contain:

  • data from hospital or ambulance databases
  • injury data where the injury did not result in a fatality
  • information about the perpetrator in assault cases.

Data contained in the NCIS is coded by court staff in the coronial jurisdiction where the investigation was undertaken. Every effort is made to ensure the completeness of coding, however when information is not collected as part of the coronial investigation it cannot be entered into the NCIS.

Case Status

Cases are added to the NCIS at the time of notification to the Coroner. During the investigation, the case status is listed as ‘open’. Case details are updated throughout the investigation. On completion of the coronial investigation, when a cause of death has been determined and the Coroner has made a finding, all case details and documentation are finalised and the case status is changed to ‘closed’ on the NCIS. Typically it is only closed cases that are included in public statistics and accessible to researchers.

Access to open cases is available in exceptional circumstances and requires the express written consent of the relevant Coroner(s). Information about NCIS case closure rates is available in Operational Statistics.

Changes in Published Figures

The NCIS is continually updated as cases are closed and quality assured. The NCIS performs a formal quality review process in which every non-natural death is reviewed to ensure the coded information is consistent and accurate. As new information comes to light, historical cases may also be re-opened by a Coroner. Occasionally this results in changes to data. As a result, there may be some changes to published mortality figures over time.

Medico-Legal Documentation

Each case contained on the NCIS includes coded data and supporting medico-legal documentation. Documentation includes the following:

  • Police Summary of Circumstances
  • Toxicology Report
  • Autopsy Report
  • Coronial Finding

Documentation is attached as a searchable PDF. These are copies of the original documents produced throughout the coronial investigation.

Not every case contains all four documents. There are instances where certain procedures are not performed and therefore no documentation is produced. Other limitations relate to the transfer of documentation. The availability of documentation varies across jurisdictions. This variation has the potential to impact the accurate identification of relevant cases via keyword search of documents on the NCIS.

 Information about NCIS document attachment rates is available in Operational Statistics.


Calculating the rate of death per 100,000 of usual resident population can be done using the Australian Bureau of Statistics (ABS) Estimated Resident Population (ERP) figures for each relevant area for the corresponding years of data. ERP figures are available here.

The formula to calculate the rate of deaths per 100,000 usual residents for an area in a single year is as follows:

Restricted Cases

Cases contained on the NCIS database can be restricted at the discretion of the State or Chief Coroner. This means the case will not be returned in a search and may not be included in any reporting. Restricted cases are only accessible to users with NCIS Administrative permission. Case restriction acknowledges the sensitivity of coronial information and allows Coroners to restrict access to cases that are particularly sensitive in the community.

Sudden Unexpected Death of Infants

The term Sudden Unexpected Death in Infancy (SUDI) is used to describe the unexpected death of an infant when there is no determined pathological or clinical reason. The coding of SUDI cases is dependent on the cause of death as determined by the Coroner and pathologist.

Terminology Within the Medical Cause of Death

Coding in relation to assigning the medical cause of death is based on the professional opinion of the investigating forensic pathologist about the factors involved in a death. The terminology used by forensic pathologists is not standardised.

Reference to particular injuries, diseases or drugs within the medical cause of death is not subject to standardised terminology. Drug detection levels that warrant inclusion in a medical cause of death are also not standardised. Lack of standard terminology can influence the identification of cases based on the medical cause of death.

Data Fields

The NCIS contains a subset of the material generated during a coronial investigation. Data entry occurs within the local case management systems at the Coroners Courts in each jurisdiction by coronial clerks.  Regular, secure data uploads from the court systems allow data to be added to the NCIS in a timely manner. Where possible, validation rules are incorporated into the local systems which strengthen the validity of the data and limit manual errors at the point of data entry.

NCIS Core Data Set

The NCIS core data set includes:

Case Demographics Name
Age and Age Units
Marital Status
Indigenous Status (AUS)/Ethnicity (NZ)
Employment Status
Place of Birth
Case Type Natural Cause
External Cause
Unlikely to be Known
Body Not Recovered
Intent Unintentional
Intentional Self-Harm
Legal intervention
Operations of War, Civil Conflict and Acts of Terrorism
Complications of Medical and/or Surgical Care
Undetermined Intent
Other Specified Intent
Unlikely to be Known
Cause of Death Medical Cause of Death
Event Circumstances Address of Usual Residence
Time and Location – Incident/Death/Body Found/Last Seen Alive
Causative or Contributing External Factors Mechanism of Injury
Object or Substance Producing Injury
Procedural Information Inquest Held
Coroners’ Recommendations Made
Death Notification Date/Death Investigation Closure Date
Externally Provided Codes ICD-10/ICD-10-AM Cause of Death Codes
Full Text Reports Police Summary of Circumstances
Autopsy Report
Toxicology Report
Coroner’s Finding

Cause of Death – ICD-10

The International Classification of Diseases, Tenth Revision (ICD-10) is published by the World Health Organisation (WHO) and uses unique alphanumeric codes to classify the disease, morbid conditions or injuries which cause or contribute to death. Australian ICD-10 coding is prepared annually by the Australian Bureau of Statistics (ABS) and provided to the NCIS in accordance with the Causes of Death Australia release. More information about the release and ABS coding is available here.

New Zealand ICD-10-AM coding is prepared by the New Zealand Ministry of Health (MoH) and provided annually to the NCIS.

Cause of Death – Medical

Diagnosis of the medical cause of death as determined by the investigating forensic pathologist.

Objects/Mechanisms as Contributory Factors to Death

Contextual or environmental factors with a cause or contribution to death are coded as the object and mechanism causing death. In order to reflect the context in which an event or injury resulting death occurs, the NCIS database accommodates primary, secondary and tertiary object and mechanism coding.


Reporting on Prescription Status

Illicit and prescription drugs are frequently involved in fatalities reported to a Coroner. In a coronial setting, any involvement of drugs is determined through post-mortem toxicological testing of blood or other specimens.

While there are several drugs which can clearly be classified as illicit, such as heroin or MDMA (Ecstasy), there are a range of compounds detected during toxicological testing which may stem from a range of sources.

For example, Codeine, a powerful pain medication, may have been ingested as:

  • a Panadeine® tablet, available over the counter and without a prescription in Australia, or
  • a Panadeine Forte® formulation in a prescription medication, or
  • as a by-product of illicit drugs.

Therefore, the classification of illicit and prescription drugs in a post mortem setting is challenging.

Caution is advised when reporting on the prescription status of fatalities involving drugs. The presence of a drug in a post-mortem specimen does not include any contextual information. Identification of prescription status via review of the case circumstances in the coronial findings and autopsy report is possible, however this information may not be routinely recorded.

Reporting on ‘Ice’

Crystal methamphetamine is colloquially known as ‘Ice’ in Australia. Ice is most commonly ingested by smoking, causing a stronger and faster effect than its powdered version, often referred to as ‘speed’. In Australian media reporting, the term ‘ice’ is often used loosely for any form of methamphetamine. Regardless of which type of methamphetamine is ingested by an individual, the toxicological screening will show a positive result for methamphetamine. It is therefore not possible to draw conclusions as to whether ‘ice’ or a powdered form of the drug was ingested by the deceased and caution is advised when reporting on the form of methamphetamine ingested by the deceased.

Alcohol Levels

The blood alcohol concentration (BAC) of a deceased person is routinely established during toxicological testing. The interpretation of these results can be challenging as there is a possibility of alcohol being produced after death due to microbiological contamination and a range of other post-mortem changes. With any BAC reported in a post mortem context, it must be noted that the concentration detected may not necessarily be reflective of the BAC at the time of death.

Finding of Mixed Drug Toxicity

Terminology used by a pathologist or Coroner to describe cause of death is not standardised. In cases where more than one drug is deemed to have made a notable contribution to the death, the term mixed drug toxicity is frequently used to describe the cause of death. Without the pathologist or Coroner specifically commenting on which particular drug is deemed to have been the main contributor to death, the NCIS is not able to provide more specific coding of these cases.

Employment Status

This field refers to the status of employment and not the type of employment. It is a controlled field and options for coding include; Employed, Unemployed, Student, Home Duties, Child Not at School, Retired/Pensioner, Prisoner, Other, Unlikely to be Known.  This code does not reflect type of employment or previous employment status. For the type of employment or profession see Usual Occupation.

Usual Occupation

This term refers to the usual job or duties in which the deceased was engaged. It does not reflect previous occupations. The “Usual Occupation” free text field is a mandatory field in the NCIS data set. A separate value from the Australian and New Zealand Standard Classification of Occupations (ANZSCO) may also be selected by jurisdictions in the “Usual Occupation” field, but it is not mandatory.



Geocoding of Address Data

Geocoding is the process of converting a street address to geographic coordinates of latitude and longitude.

Geocoding also refers to the process of assigning geographic boundaries such as Local Government Areas (LGA) to latitude and longitude data.

The residential and incident addresses for almost all closed Australian cases on the NCIS have been geocoded. The NCIS uses the Australian Bureau of Statistics (ABS) Australian Statistical Geography Standard (ASGS) Version 2016 as the main structure to assign boundary areas; SA2, SA3, SA4, RA.  LGA is also used.

Geocodes are not applied to the location of: ‘death’, ‘last seen alive’ or ‘body found’ address codes.

Limitations of Geocoding

There are occasions where it is not possible to assign a valid geographic boundary to a residential or incident location in the NCIS.  In these instances an indication will be made on the NCIS record that the address could not be geocoded. These instances include when:

  • The deceased has no fixed address or it is not known
  • The address is outside Australia

New Zealand cases have not been geocoded.

In instances where the incident address is a physical location without a standard street address, the NCIS will produce a geocode for the nearest street or suburb to the physical location. These instances include but are not limited to:

  • Beaches
  • Areas of water
  • Particular locations on railway lines
  • Railway stations
  • National Parks
  • Bushland
  • Landmarked points on a stretch of road
  • Mines
  • Bridges
  • Cliffs/Lookouts

Indigenous Status and Ethnicity

The Indigenous Status of a deceased person is primarily sourced from the Police Summary of Death form provided to the investigating Coroner. Dependent on the case, this information if often not known or not collected. In cases where no information about the indigenous status of the deceased person is available, the indigenous status field on the NCIS database is coded as Unlikely to be Known. Jurisdictional comparisons of fatalities among indigenous persons must take into account these limitations. Indigenous Status is relevant only to Australian cases.

New Zealand cases refer to Ethnicity and this field is unique to New Zealand. Ethnicity refers to the ethnic group or groups with which individuals identify and is a cultural affiliation rather than a race. When there is no information about ethnicity contained in the coronial file, the Ethnicity field on the NCIS is coded as Not Specified.

Intent Type

NCIS case data is coded by staff in each coronial court in Australia and New Zealand based on the finding of the investigating Coroner. Where a Coroner specifically states in a finding that the deceased intentionally self-inflicted harm, regardless of whether the anticipated outcome was death, the NCIS coder will assign the intent as Intentional Self-Harm (ISH).

When a person dies as a result of their own actions, it can be difficult to ascertain the intent of the person at the time the action was taken. Coroners attempt to make a determination about the intent of the person at the time the action was taken, and are bound by legal requirements. All NCIS intent coding is based on the coronial finding.


This code refers to a location type such as a house, commercial building, road etc. It does not refer to a specific geographic location or address.

Marital Status

This code refers to the marital status of the deceased at the time of death. The term ‘married’ includes de facto spouse including couples of the same sex.

Perpetrator Relationship to Deceased

In cases coded with an intent code of Assault, the relationship field indicates if there was an existing relationship between the perpetrator and the deceased person, and if so, the nature of that relationship.  The relationship definitions were developed by the NCIS. The NCIS does not contain any data about perpetrators.


The term sex refers to the biological differences between males and females, while the term gender refers to the social identification of sex. The ABS advises that the correct terminology for this data item is sex.