Coroner Findings Highlight Important Lessons for Health Practitioners
13 Aug 2026
How Ahpra shares coroners’ recommendations
Ahpra publishes case summaries of coroner referrals on its website. These summaries identify the deceased person and include the coroner’s recommendations in full, with links to the relevant coroner or court website.
When a case has broader implications for a profession, the relevant Board may also publish a summary and highlight key issues for practitioners.
Health professionals are encouraged to regularly check the Ahpra website for new referrals and recommendations.
Cases referred for professional education
Psychology Board of Australia
An inquest into the death of an adolescent, identified as KP, was conducted by the State Coroner of Victoria.
Finding date: 5 April 2017
The Psychology Board of Australia published a summary of the coroner’s recommendations for practitioner education.
Nursing and Midwifery Board of Australia
The Coroner’s Court of Victoria conducted an inquest into the death of Caroline Emily Lovell.
Finding date: 24 March 2016
The Nursing and Midwifery Board of Australia published a summary of the recommendations. The full recommendations are available through the Coroner’s Court of Victoria.
Medical Board of Australia
An inquest into the death of Summer Alice Steer was conducted by the Office of the State Coroner, Queensland Courts.
Finding date: 3 November 2015
The Medical Board of Australia published a summary of the coroner’s recommendations. The full recommendations are available through the Queensland Courts.
Medical Board of Australia
An inquest into the death of Amber Sweetman was conducted by the State Coroners Court of South Australia.
Finding date: 26 March 2012
The Medical Board of Australia published the coroner’s recommendations for practitioner education. The full recommendations are available through the Courts Administration of South Australia.
Coroner Findings Highlight Important Lessons for Health Practitioners
Source: Australian Health Practitioner Regulation Agency (Ahpra) and relevant National Boards