Deaths at a major hospital were incorrectly certified by an experienced former staffer who acted outside the law and signed off on patients he hadn't seen, a review has found.
Tasmania's Launceston General Hospital was the subject of a review after a nurse accused former head of medical services Dr Peter Renshaw of falsifying death certificates.
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The review, which released its final report on Friday, has recommended 29 deaths be referred to the coroner for investigation.
There were 28 "inaccurately attested" medical certificate cause of death (MCCD) forms which reviewers recommended be referred to authorities.
A former staff member, who the review has not named, repeatedly acted outside the scope of the births, deaths and marriages act.
"(They) repeatedly inaccurately represented their standing to certify MCCDs the relevant attestation on those MCCDs," the review said.
"The panel considers this a serious and sustained departure from the expected standards of knowledge, skill, and judgment for an experienced medical administrator."
The review recommended the former staff member be reported to the Medical Board of Australia.
"This is on the basis that there is a consistent pattern of cases in which they have certified deaths which prima facie they were not qualified to certify," the review said.
"(They) incorrectly attested as a medical practitioner who attended the patient in their last illness."
Tasmania's health department has committed to the recommendations and will also refer the report to Tasmania Police and the Australian Health Practitioner Regulation Agency.
"The department ... is committed to providing the families with the information and support they require and ... is in the process of contacting affected families," acting department secretary Dale Webster said.
There were several cases where deaths should have been reported to the coroner, the review said, although it noted there was no evidence of systemic problems at the hospital.
The reviewers emphasised referrals to the coroner were being made in the interests of transparency.
"No inference should automatically be drawn that there is something suspicious or otherwise untoward about the deaths ... or the causes of death cited on the MCCDs," they said.
The department has also adopted recommendations to improve policies, protocols and training to ensure accurate death certification and compliance with statutory requirements.