About investigations and inquests
When an investigation is needed
The Coroner must investigate where someone has died:
- a violent, unnatural or unexpected death
- from an injury or accident
- from an incident or injury at their workplace, and not apparently of natural causes
- during or after a medical procedure, where the death might be linked to the procedure; and a doctor would not, immediately before the procedure was done, have expected the death
- from an unknown cause
- when a doctor won’t issue a medical certificate for the cause of death
The Coroner must also investigate:
- the sudden and unexpected death of a child under the age of 1
- the death of someone in care or custody immediately before their death
- the death of someone escaping from prison, police custody, an institution (prison, detention centre or secure mental health unit); or while a prison officer or police office was trying to detain them.
How an investigation works
Investigations are needed to work out the circumstances and cause of death. These are usually done by the police on behalf of the Coroner, and involve taking witness statements and other evidence.
Investigations usually take 6 months, but they can take longer, due to:
- the complexity of the case, and the number of enquiries to be made
- the availability of witnesses
- the need to get expert witness reports
- the need to wait for the outcome of related criminal proceedings.
In most cases, the Coroner will end their investigation with a written ‘finding’. They will send a copy of this to the most senior next of kin.
When an inquest is needed
An inquest must be held if:
- the Coroner suspects murder
- the Attorney–General or Chief Magistrate calls for one
- the person was in care or custody immediately before their death
- the identity of the person is unknown
- the person died while escaping (or trying to escape) from prison, police custody, an institution (prison, detention centre or secure mental health unit); or while a prison officer or police office was attempting to detain them
- the person died from an incident or injury at their workplace, and the Coroner is satisfied it wasn’t natural causes
- the person died in any other circumstances that require an inquest.
An inquest may be held if the Coroner believes it will improve public safety.
How an inquest works
An inquest is a formal hearing where sworn evidence is taken in court from witnesses who can be cross-examined.
The Coroner may also receive evidence only through documents.
The Coroner’s Office can explain your rights to see or get copies of documents, to attend the inquest, or to be represented by a lawyer. Call the day before the inquest hearing for this information.