The National Coronial Information System (NCIS) is a national repository containing data on deaths reported to a coroner in Australia and New Zealand. These explanatory notes detail the collection, organisation and interpretation of NCIS data.

Data sources

The collection is sourced from each jurisdiction in Australia and New Zealand.  International Cause of Death coding is provided by the Australian Bureau of Statistics and the New Zealand Ministry of Health.

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 is provided by the following organisations: the Australian Bureau of Statistics (ABS), the New Zealand Ministry of Health and Safe Work Australia.

The NCIS incorporates supplementary data provided by the external organisations. The data and the data custodians are:

  • Causes of Death Australia: International Classification of Diseases, Tenth Revision (ICD-10) codes – Australian Bureau of Statistics 
  • Causes of Death New Zealand: International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes – New Zealand Ministry of Health
  • Indigenous Status and Place of Birth codes – Australian Coordinating Registry (which combines the state based BDM registry data into a national file). Not applicable for New Zealand cases.
  • Worker related codes including occupation, industry, and injury type (TOOCS 3.0) – Safe Work Australia (There is no equivalent data for New Zealand cases)

All supplementary data is updated annually.

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 demographic information about the deceased, contextual details on the circumstances of the fatality and searchable reports including the coronial finding, autopsy and toxicology report and the police notification of death report. Not all fatalities are contained in the NCIS. The collection contains data on reportable deaths only.

A reportable death is generally a death that is: unexpected or unexplained; the result of an accident or injury; in care or custody; healthcare related; or the person’s identity is unknown. The Coronial Act within each Australian and New Zealand jurisdiction determines what constitutes a reportable death that must be investigated by a coroner.

Deaths due to natural causes are only included in the data collection when investigated by a coroner. Deaths that are certified by a doctor are not reported to a coroner are therefore excluded.

The number of natural cause deaths on the NCIS is not representative of the number of such deaths that occur. The Australian Bureau of Statistics reported in 2017, 88.1% of deaths were certified by a doctor and the remaining 11.9% were certified by a coroner. For a detailed description of the coverage and processing of all death data (certified by a coroner or doctor) refer to the Australian Bureau of Statistics.

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. Only closed cases are included in public statistics and accessible to researchers.

Access to open cases is available in exceptional circumstances and requires written consent from the relevant coroner(s). Information about NCIS case closure rates is available in operational statistics.

Data is collected from primary source material such as the police notification of death report, autopsy and toxicology reports and coronial findings from each jurisdiction. The level of detail contained in these documents varies between and within each jurisdiction. Institutional practices and legislative differences impact the information collected and reported by each jurisdiction. Therefore, there will be differences in the qualitative and quantitative comprehensiveness of the data.

The NCIS conducts a rigorous quality review process to maintain the highest possible standards of data quality and consistency. The Data Dictionary and Coding Manual provide a national standard for coding that ensures the codeset reflects current international standards. Manual quality assurance reviews monitor and verify that the data conform to the defined, standardised codeset and provide an accurate reflection of each case.

The NCIS is continually updated as cases are closed and quality assured. As new information comes to light, historical cases may be re-opened by a coroner. Occasionally this results in changes to data so there may be some changes to published mortality figures over time.

Each case contained on the NCIS includes coded data and supporting medico-legal reports:

  • Police summary of circumstances
  • Toxicology
  • Autopsy
  • Coronial finding

Reports are 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 so no report is produced. The availability of reports also varies across jurisdictions. This has can effect the accurate identification of relevant cases using the keyword search function of the available reports. Other limitations relate to the transfer of reports.

 Information about NCIS report attachment rates is available in operational statistics.

When comparing frequencies of certain types of fatalities between geographical locations, population numbers should be considered. An increase in case frequency may be impacted by an increase in population rather than an increase in incident.

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.

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

Cases contained on the NCIS can be restricted at the discretion of the State or Chief Coroner. Coroners may restrict access to cases that are particularly sensitive in the community.

Data fields

The NCIS contains a subset of the material generated during a coronial investigation. The data is coded by court staff in each jurisdiction. The majority of data fields are pre-determined by a codeset specific to each field. Automated validation rules are incorporated into the database and the data is quality assured and organised to facilitate search and discovery.

The NCIS core data set includes:

Case Demographics Name
Age and Age Units
Sex
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
Assault
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 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.

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

The NCIS does not quality assure the ICD-10 coding provided by the ABS.

Cause of death – medical

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

Terminology within the medical cause of death

Coding of the medical cause of death is based on the professional opinion of the investigating forensic pathologist about the factors involved in a death.

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. This can influence the identification of cases based on the medical cause of death field.

Reporting on prescription status

Illicit and prescription drugs are frequently involved in fatalities reported to a coroner. Any involvement of drugs is determined through post mortem toxicological testing of blood or other specimens.

The classification of illicit and prescription drugs in a post mortem setting can be challenging. 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 different 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.

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. Identifying 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. 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. Interpreting these results can be challenging as it is possible for alcohol to be 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.

Options for employment status 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.

Geocoding of address data

Geocoding is the process of converting a street address to latitude and longitude coordinates. It also refers to the process of assigning geographic boundaries such as Local Government Areas (LGA).

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.

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. The cases will be marked on the NCIS record as not geocoded. These instances include when:

  • The deceased has no fixed address or it is not known.
  • The address is outside Australia.
  • The geocoding software is unable to provide a sufficiently accurate geocode.

New Zealand cases have not been geocoded.

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. This includes, but is 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 or lookouts

The indigenous status of a deceased person is primarily sourced from the police summary of death form provided to the investigating coroner. This information if not always known or 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 is coded as Not Specified.

NCIS data is coded by court staff based on the finding of the investigating coroner. Where a coroner specifically states that the deceased intentionally self-inflicted harm, regardless of whether the anticipated outcome was death, the intent will be coded as Intentional Self-Harm.

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 and are bound by legal requirements. All NCIS intent coding is based on the coronial finding.

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

Marital status coding refers to the marital status of the deceased at the time of death. The term ‘married’ includes de-facto couples.

Contextual or environmental factors that cause or contribute to death are coded as the object and mechanism causing death. To reflect the context in which an event or injury resulting death occurs, the NCIS accommodates primary, secondary and tertiary object and mechanism coding.

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.

Sex refers to the biological differences between men and women, while gender refers to the social identification of sex. The Australian Bureau of Statistics advises that the correct terminology for this data item is sex.

Sudden unexpected death in infancy (SUDI) describes the unexpected death of an infant when there is no determined pathological or clinical reason. The coding of SUDI cases depends on the cause of death as determined by the coroner and pathologist.

Usual occupation refers to the regular job or duties in which the deceased was engaged in at the time of death. 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 coded field, but it is not mandatory.