About | Coroners Court

Message from the Chief Coroner

The death of a loved one is one of the most traumatic experiences of life. I extend my sympathy if you have experienced such loss.

When a death is sudden and unexpected, the shock of loss can be felt even more keenly. If you need help to cope, please do not hesitate to ask. There is a list of support groups in this guide that can provide assistance at no cost.

Most people do not have any contact with the coroner’s court unless a person close to them dies suddenly. They do not understand why a coroner is involved and what the coroner is required to do. This uncertainty can add to the stress felt at this already difficult time.

This website will help families and friends of people whose deaths are being investigated by the coroner to understand what is happening and why it has to happen. It will answer a lot of the questions you have about the coronial process.

If there is anything else you want to know, please contact the coroners’ office. It is very important to us that you understand what is happening and we will always provide information if it is possible.

Olivia McTaggart
Chief Coroner

What does the coroner’s court do?

The Coronial Division of the Magistrates Court (or the ‘coroner’s court’) investigates certain deaths, fires and explosions by collecting and examining evidence and making findings. There are a lot of people involved in this process, most importantly, the families and friends of people who have died suddenly. Often the coronial process is an emotional one and friends, families, employees and professionals and others touched by a death need many levels of help and support.

The purposes and objectives of the coroner’s court are to:

identify deceased persons
find out how and why a person died
establish the cause and origin of fires and explosions
learn from experience to help prevent similar deaths occurring
improve our systems of public health and safety

further the administration of justice

allay suspicions and fears
hold public agencies to account for deaths in the State’s custody or care; such as police, prisons and health services
investigate in public where appropriate
reinforce the rule of law in democratic societies
provide quality assurance in the death investigation process.

Coronial investigations involve a delicate balance between the rights of the public and the rights of the individual. It is important to protect the privacy of individuals, especially the deceased who can no longer speak for themselves. Families have a right to privacy and a period of grief, but often they feel the need to know what happened to their loved one. The promotion of public health and safety is amongst the most important roles for the coroner’s court and sometimes the knowledge gained from a detailed investigation of a particular death can assist greatly in preventing deaths. In cases involving public agencies, transparency and accountability may be aided by disclosing information to the public in general. Impartial pursuit of the truth is paramount, but coroners also aim to be sensitive to the bereaved. In all aspects of their investigations, coroners strive to find balance.

Reporting of deaths

Approximately 900 deaths are reported to the coroner in Tasmania each year (the Magistrates Court : Annual Report 2021 - 2022 are available on the Magistrates Court web site, under Publications). All deaths that are reported are investigated (s 7(c)), with the depth of the investigation depending on the circumstances of the case. Of the deaths that coroners investigate, approximately 40 per cent are natural deaths. A natural death does not fall under the jurisdiction of the coroner’s court. The concept of a ‘natural death’ is very complicated both medically and legally, therefore the determination that a death was “natural” can occur at any stage in the investigation. As a result, the amount of time and resources required for each natural death varies. Once a death is confirmed as natural, the investigation is completed as soon as is practicable. In the remaining 60 per cent of deaths, a comprehensive investigation is undertaken. These matters are conducted either by a coroner making findings in chambers or, in a minority of cases, by a public inquest.

Section 3 of the Act states that a reportable death occurs when:

The deceased person is in Tasmania, or connected to Tasmania, that is,

a death where –
- the body of a deceased person is in Tasmania; or
- the death occurred in Tasmania; or
- the cause of the death occurred in Tasmania; or
- the death occurred while the person was travelling from or to Tasmania –
- AND one of the following applies:
  - being a death –
    - iv. that appears to have been unexpected, unnatural or violent or to have resulted directly or indirectly from an accident or injury; or
    - v. that occurs during a medical procedure, or after a medical procedure where the death may be causally related to that procedure, and a medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death; or
    - vi. . . . . . . . .
    - vii. the cause of which is unknown; or
    - viii. of a child under the age of one year which was sudden and unexpected; or
    - ix. of a person who immediately before death was a person held in care or a person held in custody; or
    - x. of a person whose identity is unknown; or
    - xi. that occurs at, or as a result of an accident or injury that occurs at, the deceased person’s place of work, and does not appear to be due to natural causes; or
the death of a person who ordinarily resided in Tasmania at the time of death that occurred at a place outside Tasmania where the cause of death is not certified by a person who, under a law in force in the place, is a medical practitioner; or
the death of a person that occurred whilst that person was escaping or attempting to escape from prison, a detention centre, a secure mental health unit, police custody or the custody of a person who had custody under an order of a court for the purposes of taking that person to or from a court; or
the death of a person that occurred whilst a police officer, correctional officer, mental health officer or a prescribed person within the meaning of section 31 of the Criminal Justice (Mental Impairment) Act 1999 was attempting to detain that person.

There are some relevant definitions in section 3 of the Act:

correctional officer means a correctional officer within the meaning of the Corrections Act 1997;
detention centre has the same meaning as in the Youth Justice Act 1997;
medical procedure means a procedure performed on a person by, or under the general supervision of, a medical practitioner and includes –
- imaging; and
- an examination whether internal or external; and
- a surgical procedure;
mental health officer means a mental health officer within the meaning of the Mental Health Act 2013;
person held in care means –
- a child, within the meaning of the Children, Young Persons and Their Families Act 1997, in the custody or under the guardianship of the Secretary, within the meaning of that Act;
- a person detained or liable to be detained in an approved hospital within the meaning of the Mental Health Act 2013 or in a secure mental health unit or another place while in the custody of the controlling authority of a secure mental health unit, within the meaning of that Act;
person held in custody means –
- a person in the custody or control of –
  - a police officer; or
  - a correctional officer; or
  - a mental health officer; or
  - the controlling authority of a secure mental health unit; or
  - a prescribed person within the meaning of section 31 of the Criminal Justice (Mental Impairment) Act 1999; or
  - a person who has custody under the order of a court for the purposes of taking the person to or from a court; or
- a person detained –
  - in a prison as defined in the Corrections Act 1997; or
  - in a building or part of a building at a police station used for the confinement of persons under arrest or otherwise lawfully detained in custody; or
  - in a detention centre;
secure mental health unit means –
- a secure mental health unit within the meaning of the Mental Health Act 2013; or
- any other place in which a person is being detained while in the custody of the controlling authority of a secure mental health unit.

Anyone who becomes aware of a reportable death must report it to the coroner or the police, if they believe it has not been reported (s 19(1)). A death can be reported orally but the report must be confirmed in writing within 48 hours (rule 4). Usually the coroners’ associates or police will complete the written notification on behalf of a person who makes an oral report of death. Almost all deaths are reported to the coroner by police officers or medical practitioners.

If a person was in care or custody, was trying to escape from care or custody or was about to be placed in care or custody when they died, the person in whose care or custody they were held must report the death as soon as possible. In all cases, the person who reports the death, and any police officer, must provide as much information as they can to help the coroner in the investigation (s 20).

There are special provisions in the Act which relate to ‘Aboriginal remains’; this refers to historical remains and does not apply to a recently deceased Aboriginal person. Section 23 applies to human remains that the coroner suspects may be the remains of an Aboriginal person buried in accordance with Aboriginal custom. If the coroner suspects this to be the case at any stage after the death is reported, they must immediately cease all investigations and refer the matter to an Aboriginal organisation approved by the Attorney-General. This organisation then conducts its own investigation to establish if the human remains are Aboriginal. If it determines that the remains are Aboriginal, then the Aboriginal organisation takes over the investigation. If it determines that the remains are not Aboriginal, then the matter is referred back to the coroner for the usual investigation to occur.

If you are a medical practitioner and you’re seeking information on reporting deaths and the issuing of Medical Certificates of Cause of Death, please refer to the information provided in Medical Practitioners

How is the coroner’s court different from other courts?

The coroner’s court is generally inquisitorial, with few adversarial elements

Most courts are “adversarial” in nature; this means that there are two opposing sides (such as prosecution and defence). Both sides argue that the judge should accept their own case.
In an “inquisitorial” court, there are no sides: there is simply a search for the truth in which all parties collaborate. Each party may still wish to emphasise certain facts over others. Judges in inquisitorial courts do not rely on others to give the information to them; rather they investigate actively and find things out for themselves.

The rules of evidence do not apply

The Coroners Act 1995 (‘the Act’), specifies in section 51 that the rules of evidence do not apply to coronial proceedings. Instead, coroners may inform themselves in any manner the coroner reasonably thinks fit.

This flexibility allows coroners to take into account materials that would not be admissible in a criminal trial, such as hearsay and non-expert opinion evidence.
Relevance is still paramount in coronial matters: the relevant issues define the scope of the investigation (and of the inquest, if one is held).
Enquiries made by the coroner must be relevant to the manner and cause of death; therefore, all parties are prevented from pursuing causation to its extreme (refer to ‘Key Elements in the Process: Inquests – Causation, scope and relevance’).

The common law has less effect

Section 4 of the Act states that ‘a rule of the common law that, immediately before the commencement of this section, conferred a power or imposed a duty on a coroner or a coroner’s court ceases to have effect’.

This provision removes the common law jurisdiction of the coroner’s court.
It is most likely that ‘duties imposed on a coroner’ are procedural duties. A similar provision in the Coroners Act 2003 (Qld) expressly states as examples that coroners are not required to view a body or sit with a jury.
Coroners remain bound by the authorities and judicial pronouncements of courts in interpreting the legislation.

The coroner’s court is neither criminal nor civil in nature

A coronial inquest is an inquiry not a trial. Coroners are concerned with fact-finding, not determining guilt and delivering punishment.
Coroners are not permitted to include in their findings a statement that a person is, or may be, guilty of committing an offence (Act ss 28(4) & 45(3)).
Coronial proceedings are not criminal or civil in nature, but they may open the way for proceedings of either type.
Criminal proceedings may result through referral of the case to the Attorney-General and the Attorney-General / Director of Public Prosecutions preferring charges.
Civil proceedings may result through the disclosure of evidence that potentially supports the argument that a person or entity was negligent or responsible in some way for the death, fire or explosion.
There may also be repercussions as to internal disciplinary proceedings, tribunals, commissions and similar.
It is important that practitioners do not discount the consequences that coronial proceedings may have for their clients or treat an inquest as a mere precursor to future court proceedings.

The civil standard of proof applies

The coroner must establish facts on the balance of probabilities.
The standard expressed in the matter of Briginshaw v Briginshaw (1938) 60 CLR 336 at 362 is also relevant where a serious allegation is made, which it is necessary to determine, and the determination of that allegation will (or could) reflect adversely on a person:
‘…reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal. In such matters ‘reasonable satisfaction’ should not be produced by inexact proofs, indefinite testimony, or indirect inferences. Everyone must feel that, when, for instance, the issue is on which of two dates an admitted occurrence took place, a satisfactory conclusion may be reached on materials of a kind that would not satisfy any sound and prudent judgment if the question was whether some act had been done involving grave moral delinquency.’

The focus can be on the system, the individual or both

Unlike in criminal proceedings, some coronial investigations will focus on the acts of individuals, where others will focus on systemic issues.
Many coronial investigations into deaths involve mistakes and accidents by professionals, rather than deliberate acts of malice.
In such situations, coroners realise that:
mistakes and accidents are part of the execution of professional duties
good people make mistakes
most mistakes do not have negative consequences.
When the coroner makes recommendations in these matters that are aimed at prevention, there is often less focus upon individual blame and error. The accidents and mistakes of individuals are often the least controllable aspects of a sequence of events.
A systemic focus enables recommendations that anticipate, compensate for, detect, correct and prevent the mistakes that can lead to tragic events.
These coronial matters involve learning lessons from systemic errors and creating environments in which those errors, on average:
are less likely to occur
will have less severe consequences if they do occur
are more likely to be detected and
can be more easily corrected.
The criminal and civil aspects of the legal system are ‘blame-based’ and it can be challenging for legal practitioners to change their focus from the criminal or civil responsibility of individuals.

Last updated: 16 July 2024