What is a coronial inquest?
A coronial inquest helps to properly investigate ‘reportable deaths’ including sudden, unexpected, unexplained, or suspected deaths. It is a public legal process to help determine the identity of a person who has died as well as the date, place, manner and cause of their death.
Each Australian state and territory has different legislation and administrative systems governing the operation of coronial inquests. Each state and territory does however have similar approaches to the conduct of an inquest.
The NSW Coroners Court operates under the Coroners Act 2009.
What’s the difference between a coronial investigation and a coronial inquest
An investigation will be conducted in the first instance when a death is referred to the Coroner. An investigation or inquiry is also carried out to examine the cause and origin of events that cause damage to property but do not cause deaths, such as a fire or explosion.
If there are unresolved issues at the conclusion of the investigation, then an inquest can be held. The following issues can be explored
- the identity of the deceased person
- the date of death
- the place of death
- the manner and cause of death.
What factors are considered in deciding whether an inquest should be held?
The Coroner has the role of deciding whether an inquest should be held to consider and determine issues that remain unresolved following the coronial investigation.
The following will be reviewed
- the deceased’s medical history
- the circumstances of the death
- the post-mortem and pathology
- reports from specialists and investigators engaged by the Coroner
- statements from witnesses, including family and friends.
In making the decision whether to hold a coronial inquest, the Coroner takes the wishes of the family of the person who died into account.
Individuals and organisations may request the Coroner to hold an inquest. This request must be in writing and outline reasons why it should be held.
Issues of process & procedure during an inquest
The Coroner decides how the inquest is to be conducted assisted by a lawyer with the title “Counsel Assisting”.
The rules of evidence that apply to other courts do not strictly apply in the Coroners Court but to lay persons, the proceedings at inquest will still appear like a court hearing.
The Coroner determines what information, what issues and which individuals can give evidence (known as “interested parties”)
Generally, the Coroner obtains evidence from questioning witnesses and from statements that have been provided as well as other documents.
and are generally legally represented. The Coroner, Counsel Assisting or the lawyer representing an interested party may ask questions of other interested parties.
Inquests are generally open to the public. Although in appropriate cases, the Coroner has the power to exclude individuals or the broader public from attending and also prohibit the publishing of evidence.
After hearing all the evidence, the Coroner will generally require written submissions from all interested parties. The submissions restate the position of the parties on the evidence and the matters they wish the Coroner to consider.
How lengthy is an inquest?
Inquests can occupy a day or extend to many weeks.
The length of an inquest depends on the complexity of the issues and the number of witnesses and interested parties giving evidence.
Before the formal inquest starts, those involved in the inquest will attend a short hearing – a directions hearing – to have procedural questions answered including the anticipated duration.
Common outcomes of a coronial inquest
There are four possible outcomes when a death is referred to the Coroner.
- The Coroner decides to dispense with an inquest because the identity of the person who has died and the details surrounding their death are clear. Almost all deaths reported to the Coroner are completed without an inquest.
- The Coroner suspends an inquest after it starts. This happens if the Coroner determines that a person may have contributed to the death, and there is sufficient evidence to refer the matter to the Director of Public Prosecutions (DPP). The Coroner must also suspend an inquest if advised that a person has been charged with an indictable offence connected with a death.
- The Coroner holds an inquest and delivers (a) findings.
- The Coroner holds an inquest and delivers (a) findings with recommendations.
The Coroner must make a formal finding at the end of an inquest. The finding is a narrative of the Coroner’s decision. The Coroner may also make recommendations to public authorities to help prevent similar deaths from occurring again.
The finding is a different document to the post-mortem or autopsy report. The Coroner orders a forensic pathologist to complete a post-mortem or autopsy and report to help determine the cause of death. The Senior next of kin of the person who has died has the right to object to a post-mortem as well as organs being held following a post-mortem.
The Coroner delivers the finding in court. In some inquests, the Coroner will deliver the finding on the last day of the hearing. In more complex inquests, the Coroner will adjourn the hearing to a later date. The finding is also sent to the senior next of kin and other people as directed by the Coroner.
Talk to specialists in medical law
The Health & Medical Law team at Catherine Henry Lawyers has extensive experience in successfully acting for families and loved ones of a person who has died or for other individuals and organisations appearing in coronial inquests.
Its lawyers and support staff listen to and understand their client’s wishes. They guide clients through every step of the coronial process and connect them with support services.
Services include advice or representation on
- objections to post-mortems or autopsies
- objections to organs being held following a post-mortem
- seeking a coronial inquest where one has not been referred to the Coroner
- preparing evidence for a coronial inquest
- preparing and presenting submissions to a coronial inquest
- instructing Counsel at a coronial inquest
- reviews of coronial decisions – through the court where the death was reported, the State Coroner and State Supreme Court.
You can find out more about Catherine Henry Lawyers’ coronial inquest services here or view its other information resources here. To speak to a lawyer who is an expert in coronial inquests and investigations call 1800 874 949 or complete the contact form below.
