Coronial Inquests are public hearings held to examine the cause and circumstances surrounding the death of somebody in unusual circumstances. Inquests are conducted by Magistrates in their role as Coroners.

Not all deaths are the subject of a Coronial Inquest. In many instances where the cause of death is obvious and uncontroversial, there will be no inquest held.

Coroners examine reports submitted by police in respect of each death and determine which need to be further investigated. If you are a family member of a deceased person, you can request a Coroner investigate the death of your loved one, although it is ultimately a decision for the Coroner as to which deaths require an investigation and inquest.

There are certain deaths which by law must be the subject of an investigation and inquest. These include:

• all deaths in police or prison custody;
• some deaths in care (i.e. those involving mental health facilities or nursing homes for the disabled etc) where there is concern about the deceased person’s care; and
• where the Attorney-General or District Court directs that an inquest be held.

The coroner will usually be assisted at the inquest by a police prosecutor or another lawyer. That person will act as “counsel assisting” and be primarily responsible for questioning witnesses on oath. Prior to an inquest commencing, witnesses will usually have completed a statement which is formally tendered to the court at the inquest. Each witness can then be questioned about their statement, firstly by counsel assisting, then by other parties given leave by the Coroner to appear at the inquest.

In years gone by, witnesses fearful of incriminating themselves by giving evidence in an inquest could refuse to answer questions by claiming privilege against self-incrimination. Under legislation now applying to coronial inquests (for all deaths occurring on or after 1 December 2003), the Coroner has the power to direct that every witness answer questions completely. Witnesses are still allowed to formally object, but their answers still then have to be given. The benefit of claiming such privilege is that answers given upon objection cannot be used against the witness in any later legal proceedings. The thrust of these laws is to allow coronial inquests to get to the truth behind the death without being frustrated by a witness not answering questions. The “trade-off” is that the witness, while effectively forced to answer the Coroner’s questions, at least has the protection of their evidence being inadmissible against them in subsequent proceedings.

At the conclusion of the inquest, the Coroner must deliver findings in which they establish, if possible, who the deceased was, when and where the deceased died and how they died.

Other purposes of inquests

Coronial Inquests involve two other important functions. The first is the Coroner’s power to make recommendations. Part of the Coroner’s duty is to consider from the evidence whether any recommendations or opinions should be publicly expressed with a view to avoiding similar deaths in the future. For example, a coroner might recommend that further tests be conducted on a certain drug before it can be used again in hospitals, or that a certain piece of machinery should from now on be manufactured to include a particular safety feature.

The second function is for the Coroner to determine whether there is a reasonable suspicion that someone has committed an offence. A coroner may suspect that someone is responsible for the person’s death, for example, due to murder, manslaughter or dangerous operation of a motor vehicle. If the Coroner reasonably suspects such involvement, the Coroner has a duty to refer information gathered during an investigation (and inquest) to the relevant agency, commonly the Director of Public Prosecutions. The Coroner does not personally express a view about possible guilt, but simply refers the information to the proper government agency for a decision to be made.