Investigations and Inquests - What Occurs
All deaths that are unnatural, unexpected, unexplained or unattended must be reported to a coroner. Upon receiving a report of a death, the coroner begins an investigation, which ends in one of three ways:
If the coroner determines that the death was due to a natural disease process, the Coroner will contact the personal physician of the deceased to obtain information on medical history. If it is confirmed that the death is natural, the responsibility for completing the medical death certificate remains with the physician.
An investigation is conducted and a coroner’s report is written. When a death is reported to the Coroner, he/she has the authority to collect information, conduct interviews, inspect and seize documents and secure the scene.
Upon conclusion, the facts as determined by the investigation, are released on a report. It sets out the coroner’s findings, including a cause of death and whenever possible, recommendations to prevent future deaths. For a copy of the coroner's report contact the regional coroner office in your area.
Note: An investigation may be reopened on the grounds that new evidence has arisen or has been discovered. An application to reopen an investigation is made by writing a letter to the Chief Coroner outlining the new evidence.
An inquest is held and a Verdict at Inquest is written. Inquests are formal court proceedings, with a five-person jury, held to publicly review the circumstances of a death. The jury hears evidence from witnesses under subpoena in order to determine the facts of the death. The presiding coroner is responsible to ensure the jury maintains the goal of fact finding, not fault finding.
An inquest is held if the coroner determines that it would be beneficial in: addressing community concern about a death, assisting in finding information about the deceased or circumstances around a death and or drawing attention to a cause of death if such awareness can prevent future deaths.
An inquest is mandatory if the deceased was in the care or control or a police officer or in a police lock-up at the time of their death unless the Chief Coroner exercises the discretion provided under Section 18 of the Coroners Act.
Upon conclusion, a written report, the Verdict at Inquest is prepared. It includes the classification of the death and whenever possible recommendations of the jury on how to prevent a similar death. The Verdict at Inquest for some inquests is posted on the Inquest Schedule and Outcomes page. For a copy of the Verdict at Inquest that is not posted, contact the regional coroner office in your area.
Media Guide to attending Inquests
The Media Information Guide to a Coroner's Inquest (PDF) is for members of the media who are attending a coroner’s inquest.
The intent of this information package is to:
- Provide an overview of coroner’s inquests in general
- Provide guidelines and requirements for the media
- Allow for the regular, daily work of the local courthouse, or other venue, to continue without disruption
For inquest schedule information, see Inquest Schedule and Outcomes page.