When someone dies unexpectedly, a Coronial Inquest is sometimes held to understand the likely cause and manner of death. The family of the deceased can request that an Inquest take place and, in some instances, an Inquest must be conducted.

A Coronial Inquest will be held when a person’s death or suspected death is a reportable death or a medical practitioner has not given a certificate as to the cause of death.

Role of the Coroner

A coroner is the judicial officer who presides over Inquests. Some coroners may also be Local Court Magistrates.

The role of a coroner is to make findings as to:

1. the identity of the deceased;
2. the date and place of the person’s death;
3. the physical or medical cause of death; and
4. the manner of death. In other words, the circumstances surrounding the death.

At the conclusion of an Inquest, the coroner may also make any necessary or desirable recommendations including but not limited to recommendations for public health and safety or that a matter be investigated or reviewed by a specific person or body.

What is a Reportable Death?

A reportable death is defined by the Coroner’s Act when the person died:

(a)  a violent or unnatural death;

(b)  a sudden death the cause of which is unknown;

(c)  under suspicious or unusual circumstances;

(d)  in circumstances where the person had not been attended by a medical practitioner during the period of 6 months immediately before the person’s death;

(e)  in circumstances where the person’s death was not the reasonably expected outcome of a health-related procedure [a medical, surgical, dental or other health-related procedure (including the administration of an anaesthetic, sedative or other drug)] carried out in relation to the person; or

(f) while a patient at a declared mental health facility (within the meaning of the Mental Health Act 2007) for the purpose of receiving care, treatment or assistance under the Mental Health Act 2007 or Mental Health (Forensic Provisions) Act 1990.

When an Inquest must be held

In the following circumstances, the decision to hold an Inquest is not at the coroner’s discretion – ie. An Inquest must take place:

(a)  if it appears to the coroner that the person died as a result of homicide (not including suicide),

(b)  if the person died while in custody or as a result of police operations,

(c)  if it appears to the coroner that the following has not been sufficiently disclosed:

(i) whether the person has died, or

(ii) the person’s identity and the date and place of the person’s death,

(d)  if it appears to the coroner that the manner and cause of the person’s death have not been sufficiently disclosed.

When an Inquest may be held

A coroner may also hold an inquest into the death or suspected death of a person who has died, broadly:

1. while in police custody (including while escaping or attempting to escape), as a result of police operations, or while an inmate (including temporary absence or while enroute) of a detention centre, correctional centre or lock-up.
2. with respect to a child in care;
   1. a child, or their sibling, who was the subject of a report under the Children and Young Persons (Care and Protection) Act 1998 within three years prior to the child’s death;
   2. a child whose death is or may be due to abuse, neglect or occurs in suspicious circumstances;
   3. a person or child who at the time of their death was living in residential care provided under authorisation or funding under the Disability Inclusion Act 2014 or an assisted boarding house;
   4. a person with a permanent disability which results in a reduction of functional capacity and a need for support receiving assistance under the Disability Inclusion Act 2014 to enable them to live independently in the community.

In the case of fires and explosions, a Coroner may inquire as to the cause and origin of the fire or explosion in circumstances where property has been damaged or destroyed in NSW as a result of same. A Coroner may dispense with holding an inquest if they are of the opinion that the cause and origin of the fire or explosion are sufficiently disclosed or holding an inquest is unnecessary.

When might Inquests be dispensed with?

A Coroner may decide not to hold an Inquest if they are satisfied after obtaining advice from police officers, medical practitioners and consulting with the senior next of kin of the deceased that:

• the deceased person died of natural causes (whether or not the precise cause of death is known), and
• a senior next of kin has indicated to the coroner that the deceased person’s family does not wish a post mortem examination be conducted to determine the precise cause of death.

Inquest Proceedings

Coronial Inquests are inquisitorial in nature. The goal of all involved is to inquire as to the circumstances of a person’s death or suspected death with a view to making factual findings about the nature of the death.

The usual rules of evidence do not apply to Inquests. However, a witness who is called to give evidence may refuse to do so if any of the evidence they may give may tend to incriminate them in some way; for example if they have committed an offence against Australian or foreign law or may be liable to civil penalty. If this occurs, the witness may wish to seek a certificate pursuant to section 128 of the Evidence Act. If such a certificate is given, the evidence provided by the witness during the Inquest generally cannot be used against them at a later date.

Are Inquests open to the public?

Coronial Inquests will be held in an open forum unless:

1. The coroner is of the opinion that special circumstances make it necessary or desirable to do so – in which case they must record their reasons.
2. The coroner is of the view that it is in the public interest to close the court or prevent publication of evidence or submissions.
3. In the case of a self-inflicted death, the coroner expressly permits the publication of the findings if it is desirable to do so in the public interest.
4. In the case of a self-inflicted death, the coroner may order a non-publication order prohibiting the publication of any report of the proceedings until after the coroner has made his or her findings or restricting the publication of any matter identifying the deceased or a relative of the deceased.

Domestic Violence Death Review Team

In New South Wales, we have a Domestic Violence Death Review Team in place to investigate the causes of domestic violence deaths in the state, so as to:

• reduce the incidence of domestic violence deaths, and
• facilitate improvements in systems and services.

The Team must review closed Coronial Inquests involving domestic violence deaths and provide a report to Parliament every two years including patterns and trends, legislative, service or policy recommendations to reduce the likelihood of domestic violence death and systemic and procedural failures which may have contributed to any deaths.