The deaths of eight babies at Adelaide's Women's and Children's Hospital were not reported by medical practitioners over nine years, the state coroner says.
Mark Johns says in his annual report he started discussions with the hospital's chief executive after the deaths came to his attention about how those practitioners could have misunderstood their obligations to report them.
He says any death that is not reported when it should be has "serious ramifications for the necessary and required investigations into the death".
"The ability to investigate a death in a hospital once a body is disposed of and after a lengthy period of time passes results in any evidence being almost invisible," Mr Johns said in his report to state parliament.
"Any coronial analysis of possible systemic issues is very difficult under such circumstances.
"I do not consider that this is how the community would want deaths to be reported to a coroner."
Mr Johns said the hospital acted quickly to remedy the situation and had contacted most of the families involved to explain why the deaths were not reported.
But two of the families have not yet been contacted because the passing of time had made it difficult for the hospital to find them.
Mr Johns said a forensic pathologist had reviewed the hospital case notes for the infants and their death certificates and agreed with the opinions of the medical practitioners involved as to the cause of death in each case.
The coroner said he has not found any adverse events or systemic problems in treatment and care of the infants.
He said the Women's and Children's Hospital had established measures to avoid similar issues in the future but stressed it was incumbent on medical practitioners to know and understand their obligations.
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