The NSW Coroner's Office is clogged with deaths from natural causes that may have been unnecessarily reported, causing undue distress to grieving families, delaying funerals and diverting resources from genuinely perplexing cases.
More than a quarter of the coroner's annual caseload is occupied by natural-causes deaths that do not require an autopsy, with forensic pathologists usually determining a cause of death by reviewing the medical records of the deceased.
State Coroner magistrate Michael Barnes is concerned doctors might be reporting these deaths instead of issuing their own certificates out of a fear of litigation, but there are knock-on effects for families and other coronial inquiries in the pipeline.
"More and more natural-causes deaths are being referred to the coroner in Australia," Mr Barnes said.
"We frequently have very old people who have chronic disease, who have been treated on numerous occasions, and when they die in clinical circumstances that directly correlates with their history.
"Each time we get a forensic pathologist to do something they don't need to be doing, they're not doing another report."
University of Sydney researchers are working with the NSW Coroner's Office to determine why there has been an increase in the reporting of natural -causes deaths and how to reduce such cases.
The project is an inaugural grant recipient of the Sydney Policy Lab, which brings together industry, policymakers and researchers to address complex challenges.
Socio-legal studies senior lecturer Rebecca Scott-Bray said when a death was referred to the coroner, funerals were delayed and families were forced to deal with medico-legal processes that added to their stress.
"It's another layer of complication in what they have to deal with at a very significant time of their life," Dr Scott-Bray said.
The solution may be as simple as providing clearer guidelines to doctors, she said.
Doctors are required by law to report unnatural, violent or suspicious deaths to the coroner, and natural-causes deaths need be referred only if a probable cause cannot be identified.
Mr Barnes said recent medical scandals in which doctors and hospitals were accused of covering up adverse events - such as British serial killer Harold Shipman and Bundaberg surgeon Jayant Patel - might have made doctors overly cautious.
"I think there might be a misunderstanding about the level of satisfaction they need to have before they can issue a death certificate," he said.
But Royal Australian College of General Practitioners president Bastian Seidel said doctors were driven more by the need for clarity than their own aversion to risk.
Elderly patients often had multiple co-morbidities and it was not possible to tease out which one was responsible for their ultimate demise.
They also consulted several doctors, and it was difficult for a practitioner who may have seen them only once to rule on a cause of death without having their full medical history.
"In the past it was one doctor they saw - the GP - but now it's multiple doctors seeing the patient and that doesn't help," Dr Seidel said.
"If as doctor you don't know what the cause of death is, then under the law you need to run this past the coroner's office, whether you like it or not."
About 60 per cent of the 5800 deaths reported to the NSW Coroner in 2015 were by natural causes, and just under half of those - about 1500 deaths - did not require an autopsy for a cause of death to be determined.
The investigation of such deaths was considered an invasion of privacy when the Coroner's Act was set up in 1960, with the minister citing an 1884 judgment that described the prospect of a coroner interfering with funeral arrangements as "intolerable".
"Nothing could justify such interference except a reasonable suspicion that there may have been something peculiar in the death, that it may have been due to causes other than common illness," Justice James Stephen then held.
Once a death is reported to the coroner, procedures kick into play that involve the police, undertakers, mortuary workers, counsellors, forensic pathologists and coronial staff.
The body must be taken to a mortuary - usually in Glebe or Newcastle - which is particularly upsetting for religious and cultural groups that believe in maintaining vigil over their deceased kin until they can be interred.
Alex Zilich, director of the Jewish funeral operator Chevras Kadisha, said each time this happened, it held up plans and caused further anxiety to families wishing to bury their dead.
"We can't plan anything, we don't know whether they're going to be released or whether there's going to be an autopsy, which is not permitted under Jewish law," Mr Zilich said.
"The rules is the rules and we can't avoid that, but at the same time it puts families in further distress."
The Productivity Commission's latest report on court services, in 2015, indicated the NSW Coroner's Office met its key performance objective of finalising 90 per cent of cases within 12 months of them being lodged.
Natural-causes deaths that do not require an autopsy are often finalised within days, but more-complicated deaths can take months.
Kathleen MacDonald waited 11 months to get a cause of death for her 32-year-old son Jason - too late for his father who died of cancer before the final report was released.
Not only did this delay his life insurance payout, but it meant she spent almost a year agonising over whether she could have done anything differently. She feared that he may have overdosed on drugs, although ischaemic heart disease was ultimately identified as the cause.
"Because he died in my home, I was very anxious to know whether or not it was drugs," Ms MacDonald said.
"And also, knowing that [Jason's father] Eric had not much longer in this world. He was Chinese and saving face is a big part of his culture. It would have been embarrassment for him for Jason to have died from drugs.
"Eric didn't get that final report."