Coroner Services and Inquests

Information on the role of the coroner and coroner’s inquests

Last updated: 29 November 2016

What is a coroner?

The coroner’s office is responsible for investigating unexplained deaths. In Australia, each state or territory has its own coroner’s court responsible for these investigations.

Usually, a police officer or medical professional will inform the coroner of what is known as a ‘reportable death’; a death that may require investigation. This includes:

  • A death that appears to be unexpected, unnatural or violent
  • A death resulting from an accident
  • A death occurring during anaesthesia
  • A death while the person was being held in care or custody
  • When the person’s identity is unknown
  • Other circumstances that make the death unusual or unexplained

After the death is reported to the coroner, they will decide whether or not to investigate. If you feel that the death is reportable but you are not certain that it has been reported, you can do so yourself by contacting your local coroner’s office.

Autopsies

If the coroner decides to investigate further, they may order an autopsy. An autopsy, sometimes also called a post-mortem examination, is a medical examination of the body performed by a forensic pathologist. This may involve surgical procedures or taking samples for testing.

An autopsy does not necessarily mean you cannot have an open casket funeral. Talk to your funeral director to find out what is the best choice for you.

Coroner’s Inquests

After the autopsy, the coroner may decide to investigate further with a Coroner’s Inquest. This is a formal investigation which involves studying all the evidence around a person’s death to discover the cause and circumstances.

Usually the coroner will not hold an inquest if the cause of death has been discovered, or if they judge that no further information will be discovered by an inquest. They will write to the next of kin of the person who has died to explain why an inquest (a public court hearing) is unnecessary.

If you are a family member of the person who has died and you want an inquest to be held, you can write to the coroner explaining why an inquest is necessary. If the coroner refuses to hold an inquest, you can apply to the Supreme Court to try to have their decision overturned. Be advised that this may be extremely time-consuming.

If the coroner does decide to hold an inquest, this will take the form of a court hearing, which may take several weeks, depending on the complexity of the case. During the inquest, the coroner will hear evidence from witnesses, review written records, phone recordings, photos, and any other relevant evidence in order to establish what happened.

When the inquest is complete, the coroner will write up their findings in a document known as the coroner’s decision. This is made publicly available. The coroner can raise awareness not only about how the person died, but also how the death could, or should, have been prevented.

For more information about coroner services, inquests and reports, contact your state coroner’s office directly.