Coronial Process

Each State and Territory has its own Act, which governs the powers and duties of the Coroner. Accordingly, the specific duties and responsibilities of the Coroner will vary by jurisdiction. In general however, it is the role of the Coroner to investigate the circumstances surrounding all ‘Reportable deaths’. In each state and territory, with the exception of Western Australia and Northern Territory, a Coroner may also investigate fires of public significance, whether or not anyone has died. Furthermore, in some jurisdictions, Coroners also have the power to investigate explosions. Some also have jurisdiction to investigate mining related deaths.

At the conclusion of every investigation, it is the task of the Coroner to prepare a written Finding to establish wherever possible the following:-

What is a 'Reportable death'?

What constitutes a ‘Reportable death’ varies by jurisdiction. Although the following list is not exhaustive, in general, a death must be reported to a Coroner in the following instances:

Usually a police officer or a medical practitioner will notify the Coroner of any death that may be a 'reportable’ death. It is open however, to any person to notify the Coroner if they believe that a reportable death has occurred.

When is an autopsy necessary?

An autopsy or post-mortem is a physical examination of a person’s body conducted by a pathologist. An autopsy can help explain the cause of death and is part of the coronial investigation into ‘reportable’ deaths. Once a pathologist has all the results of the tests, a detailed report is prepared for the Coroner, which outlines medical findings and conclusions. The Coroner takes this information into account when making a finding.

The next of kin has a legal right to file an objection to an autopsy being conducted and the Coroner will take into consideration any such objection.

For details regarding the rights of the next of kin in a particular jurisdiction with respect to objecting to an autopsy, please refer to the appropriate legislation for that particular state or territory.

What is an inquest?

An inquest is a court hearing conducted by the Coroner, in which the circumstances surrounding a death are examined. An inquest is usually open to the public.

An inquest is a formal Court hearing. Proceedings are conducted without applying the strict rules of evidence.

During an inquest, witnesses may be called to give evidence on oath and exhibits are presented, in order to assist the Coroner in making a finding in relation to the death.

People with an interest in the circumstances of a death may, at the Coroner’s discretion, ask questions of a witness or, more commonly, a barrister or solicitor may ask questions on their behalf.

At the conclusion of proceedings, the Coroner will make a finding indicating where possible the identity of the deceased; the circumstances surrounding the death; the cause of death and the particulars needed to register the death.

It is an important part of the Coronial Process for the Coroner to consider if there are lessons that may be learned from a death. Hence, in some cases, the Coroner may comment and make recommendations about public health or safety or the administration of justice, to help prevent a similar event from happening again. In these instances, the Coronial finding is forwarded to government bodies and/or relevant agencies.

When might an inquest be held?

All ‘reportable’ deaths must be investigated by a Coroner. In certain types of death, the investigation must include an inquest. For instance, an inquest must be held if the deceased person was being ‘held in care’ immediately before his or her death. There may be an inquest in other cases if the coroner believes it is necessary.

After examining evidence, such as medical reports and witness statements, a Coroner may decide that an inquest is not necessary. In fact, only a small number of deaths reported to the Coroner will actually result in an inquest. The majority of matters will be concluded by way of a finding in chambers.

More information

More information about Australian Coroner's Offices can be found on their web sites. Links are provided in the section below.

Australian Coroners Courts / Offices

Addresses, Web Sites and Jurisdictional Coroner's Acts

Click on the underlined word to link to the selected coronial web site, Coroner's Act or Coroner's Regulations.

Australian Capital Territory Coroners Office Magistrates Court GPO BOX 370 CANBERRA ACT 2601 phone 02 6217 4231 fax 02 6217 4502	Magistrates Court Web Site	Coroners Act	Findings
New South Wales State Coroner's Office 44-46 Parramatta Road GLEBE NSW 2037 phone 02 8584 7777 fax 02 9660 7594	Coroners Court Web Site	Coroners Act	Findings
Northern Territory Coroners Office Magistrate' Court GPO BOX 1281 DARWIN NT 0801 phone 08 8999 7770 fax 03 8999 5128	Coroners Office Web Site	Coroners Act	Inquest Findings
Queensland Office of the State Coroner Level 1 Brisbane Magistrates Court 363 George Street BRISBANE QLD 4000 phone 07 3239 6193 fax 07 3247 9292	Coroners Office Web Site	Coroners Act	Coroners Regulations Findings
South Australia Coroners Office 302 King William St ADELAIDE SA 5000 phone 08 8204 0600 fax 08 8204 0615	Coroners Office Web Site	Coroners Act	Findings
Tasmania Coroners Office 21 Liverpool St HOBART TAS 7000 phone 03 6233 6202 fax 03 6233 6125 Coroners.Hbt@justice.tas.gov.au	Magistrates Court (Coronial Division) Web Site	Coroners Act	Coroners Regulations 1996 Annual Report Findings
Victoria Coronial Services Centre 57-83 Kavanagh Street SOUTHBANK VIC 3006 phone 03 9684 4444 fax 03 9682 1206	Coroners Office Web Site	Coroners Act	Coroners Regulations 1996 Booklet "The Coroner's Process - Information for Family and Friends"
Western Australia Coroners Court Level 13 May Holman Centre 32 St George's Terrace PERTH WA 6000 phone 08 9425 2900 fax 08 9321 2500	Coroners Court Web Site	Coroners Act	Annual Report Brochure "When a person dies suddenly"

What does a Coroner do?