In 2021, the granddaughter of a woman who died at the Launceston General Hospital (LGH) expressed concern about a staff member who had issued the death certificate.
The staff member responded:
"I am permitted to issue death certificates based on the documentation in a patient's record, including the date and time of death based on the observations of our medical and nursing staff documented in the medical records."
Except, it has been found, the staff member did not have this authorisation.
And it was far from a one-off occurrence.
An independent review into deaths at the LGH — which had not been referred to the coroner — found the staff member engaged in a "repeated pattern" of acting outside the scope of Tasmanian law.
As an administrator at the hospital, they did not have the authority to sign off on death certificates, the report found.
In the final report, by a panel led by Debora Picone AO, the conduct was described as "misguided", and while the staff member did not respond to the review's questions, it used the staff member's response to a patient's family as evidence of their view on their role.
"The staff member misguidedly asserts reliance on hearsay about the patient and documentary review is sufficient to enable certification which is clearly at odds with both policy and legislation," the report reads.
The review examined 86 medical records regarding deaths — 23 identified by Department of Health staff, and 65 found in a mortality module and flagged by members of the public.
Of those, 29 have been referred to the coroner for further investigation, and 28 had inaccurate documentation.
The vast majority occurred between 2020 and 2022.
The review was triggered following allegations raised in parliament by LGH nurse Amanda Duncan that former director of clinical services Peter Renshaw had falsified death certificates.
Dr Renshaw was not named in the report.
He did not respond to the ABC's requests for comment.
The government has announced it will provide the report to Tasmania Police, the Integrity Commission and the Australian Health Practitioner Regulation Agency (AHPRA) for assessment.
The staff member was referred to the Medical Board of Australia due to a "consistent pattern" of certifying death certificates when not qualified to do so.
Dr Renshaw's medical practitioner licence was suspended by the Medical Board of Australia in May.
Referral to coroner 'made in the interests of transparency, independent scrutiny'
In January, registered nurse Tom Millen told the committee LGH staff had become concerned that causes of death were not being correctly reported to the coroner.
The panel was formed in February following the allegations raised in parliament.
It released an interim report in May, outlining that it would refer six deaths to the coroner — involving unexpected deaths, post-procedure deaths and post-fall deaths.
It then started looking into another 65 deaths, and of those, 16 more were identified to be referred to the coroner, taking the total to 22.
The final report has added a further seven cases, for a total of 29.
They were cases that the panel found, based on relevant documentation, should be reported to the coroner, rather than certified by a doctor in the Tasmania Health Service (THS).
The issues centre on how medical record, mortality module, medical certificate of cause of death (MCCD) had been completed.
In the report, the panel noted that just because a matter will be referred to the coroner, does not necessarily mean that something improper occurred in the patient's treatment.
"The panel wishes to emphasise that referral to the coroner is being made in the interests of transparency and independent scrutiny," the report reads.
"No inference should automatically be drawn that there is something suspicious or otherwise untoward about the deaths in question or the causes of death cited on the MCCDs."
The report did not find systemic issues in the department, and was supportive of reforms and improved training that the department had been implementing since the allegations were raised.
All efforts will be made to contact the families involved.
Acting department secretary Dale Webster said all recommendations had been accepted.
"On behalf of the Department of Health, I apologise to the families and friends of those impacted," he said.
"The department acknowledges the distress these findings may cause, and we will actively engage with, and support, families through the open disclosure process."
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