Coronial inquests

Following a death, the coroner will hold an inquest into the death.  The purpose of this guide is to assist workplaces, families and related persons to understand their role in the investigation process.

How is the coroner informed?

A person who believes that a death is one where an inquest can be held, must report the death to a police officer or to the coroner directly.  Reportable deaths are deaths where:

  • The person’s identity is unknown;
  • The death was violent or unnatural;
  • The death happened in suspicious circumstances;
  • A ‘cause of death’ certificate hasn’t been issued and isn’t likely to be;
  • The death was related to health care;
  • The death occurred in care, custody or as a result of police operations.

It is the ordinary experience when dealing with a workplace death that the police would naturally be informed and that as a result of that, police would inform the coroner of the matter.

What happens in a coronial investigation?

Deaths are usually reported to the coroner by the police who attend the scene or by a medical practitioner.  The coroner controls and coordinates the investigation. Police officer assist the coroner to gather material and evidence.

The first steps taken by the coroner are to identify the deceased and to commission an autopsy if required, to discover the cause of death.  This will occur quickly so that the person can be released to the family for a funeral and burial at the earliest opportunity.  Ordinarily identification will be conducted through a person who knows the deceased person well. However, if that is not possible, DNA, dental or fingerprint identification is used.

A preliminary report is given to the coroner which may prompt the coroner to ask police to investigate further and gather medical material and statements from witnesses.  The coroner can seek further information from specialists including doctors and other medical practitioners, workplace health and safety inspectors, engineers and occupational regulator investigators (for example electrical inspectors, air safety inspectors, mining inspectors).

Once the coronial investigation occurs, they consider whether to hold an inquest into the death.

What happens at a coronial inquest?

An inquest is a judicial inquiry to ascertain the facts relating to an incident. Once the coroner decides to hold an inquest, a notice will be published about the inquest.  An inquest’s length will depend on the complexity of the case and the number of witnesses and relevant parties.

Before the inquest, a pre-inquest conference is held. At that time the coroner decides what issues are to be considered, who the parties are, what evidence will be called, how long the inquest will take and where to hold it.  There is usually at least one counsel assisting the coroner.  That person is responsible for calling the witnesses to give evidence.  The counsel assisting is also responsible for outlining the issues to be considered by the coroner.  The parties are able to make submissions about issues they think should be included.

People who are required to attend an inquest as witnesses will be told in advance of the inquest hearing.  You will then receive written notice about the court attendance.

At the inquest hearing itself, evidence is taken on oath or affirmation.  Each party asks questions in turn.  The coroner may also ask questions of the witness.  After all the witnesses have been heard, the evidence is closed and the parties will make submission to the coroner.

The coroner will ordinarily adjourn the proceedings to allow an opportunity to consider the evidence and give a decision as to their findings.

What are the consequences of a coronial inquest?

As a result of a coronial inquest, the coroner will produce a decision reflecting their findings.  Recommendations are often made by a coroner on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

As a result of recommendations, investigative bodies including police and workplace health and safety may take up a prosecution.