"It seems a doctor was prepared to sign a death certificate in circumstances that, in my opinion, were not appropriate. I am satisfied there are issues surrounding the death that meant the duty coroner should have been notified promptly," he said.
"It has also emerged that the standard report of death form that is prepared by the hospital for the duty coroner was prepared but not sent for some days. When the duty coroner was finally informed and took jurisdiction of the death, it emerged Mr Tepania's body was already buried.
"My office will be raising the matter with the Northland Chief Medical Officer," he said in a statement.
The case has been referred to Coroner Wallace Bain.
Northland DHB spokeswoman Liz Inch said the health board would not make any comment.
"This case is in the hands of the coroner".