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Printer friendly versionThe State Coroner:
Ensures investigations and inquests into deaths, fires, accidents and the disappearance of missing persons are properly managed
Makes what are called “findings” about the cause of death in certain cases
Decides if it is necessary to hold an inquest into the death or disappearance of a person, a fire or an accident
Conducts inquests to determine the cause or circumstances of a death, disappearance, fire or accident.
The State Coroner is a judicial officer, not a doctor. The State Coroner is assisted by a Deputy State Coroner and other Coroners, as required.
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The State Coroner’s Office is located at 302 King William Street, Adelaide.
The Coroner’s staff are people with skills in legal matters, investigation and counselling.
They receive reports of each death, conduct investigations and prepare all information for consideration by the State Coroner and if an inquest is held, for the Coroner’s Court.
Counselling is available to the family and friends of a deceased.
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The Coroner’s Court is also located at 302 King William Street, Adelaide. The Court Registry is situated on the ground floor and the courtroom is on level 1. The Court conducts inquests. Most inquests are held in this courtroom but inquests also can be held at other sites. A Coroner’s Court is presided over by a Coroner.
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Usually a police officer or doctor will notify the State Coroner of any death that may be a reportable death.
A death must be reported to the State Coroner where it has occurred:
unexpectedly, unusually or by a violent, unnatural or unknown cause
on a flight or voyage to South Australia
while in custody
during, as a result or within 24 hours of certain surgical or invasive medical procedures, including the giving of an anaesthetic for the purpose of performing the procedure
within 24 hours of being discharged from a hospital or having sought emergency treatment at a hospital
while the deceased was a ‘protected’ person
while the deceased was under a custody or guardianship order under the Children’s Protection Act
while the deceased was a patient in an approved treatment centre under the Mental Health Act
while the deceased was a resident of a licensed supported residential facility under the Supported Residential Facilities Act
while the deceased was in a hospital or other facility being treated for drug addiction
during, as a result or within 24 hours of medical treatment to which consent had been given under Part 5 of the Guardianship and Administration Act
when a cause of death was not certified by a doctor.
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Following a report of a death, the State Coroner must decide if it is necessary to hold an inquest to determine the cause and circumstances of the death.
This involves a process to identify the deceased. Visual identification is usually done by someone who knew the deceased well. Sometimes identification may need to be made through fingerprints, dental records, DNA testing or circumstantial evidence.
If the situation necessitates, a doctor or qualified paramedic will certify that death has occurred.
It may also be necessary for a post-mortem or autopsy to be performed to establish the specific medical cause of death.
The processes of identification and post mortem may mean that the release of the deceased to the family's Funeral Director is delayed.
As part of the investigation the State Coroner may direct police assigned to his office to seek further information. This does not mean that there is something suspicious or sinister about the death. Statements can be taken from witnesses relating to the circumstances of the death and police can also provide statements detailing their investigation. Reports can also be sought from experts in areas such as medicine, surgery, fire, air safety, road safety, work-place safety or engineering.
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A post-mortem examination, also known as an autopsy, is a step-by-step examination of the outside of the body and of the internal organs by a doctor known as a pathologist. The examination is carried out at the direction of the State Coroner and is usually required to establish the cause of death. Techniques similar to those in surgical operations are used.
Post-mortem examinations may also include tests for infections (microbiology), changes in body tissue and organs (anatomical histology), and chemicals e.g. medication, drugs or poisons (toxicology and pharmacology).
In Adelaide, most post mortems are performed at Forensic Science SA by a forensic pathologist.
The post mortem is conducted without unnecessary delay, although, at times of high workload and when the deceased must be transported over long distances, or over weekends or public holidays the timeframe may be longer than anticipated. After the body is released to the family's funeral director a date for the funeral can be decided.
If you require any further information in relation to a post-mortem examination, please contact the Social Worker at the State Coroner's Office on (08) 8204 0600.
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In most coronial cases a post-mortem is required to determine the precise cause of death.
However, on some occasions the State Coroner can determine the cause of death from the person's medical history and the police report on the circumstances surrounding the death.
One major benefit of a post-mortem is that it provides detailed information about the person's medical condition prior to death and so gives an understanding of the various factors that may have contributed to their death. Even if the cause of death may seem clear, the person may have had a medical condition that was not apparent during life.
This information may be very important for family members trying to come to terms with the death.
From a medical point of view, if the person died from an infection or genetic disease, a post-mortem may provide valuable information for other family members.
Essentially, a post-mortem examination is ordered by the State Coroner to ensure that a balanced and accurate finding as to the cause of death can be determined.
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The State Coroner should be advised immediately in writing of any objection to a post-mortem being conducted so that the post-mortem can be delayed whilst the objection is being considered.
Because the State Coroner has to bring down a finding as to the specific cause of death, it is his decision as to whether a post-mortem is conducted. However, the State Coroner will seriously consider objections raised by next of kin.
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Body tissue and organs require specialised examination. This varies, depending upon the cause of death. Small samples of tissue are routinely taken for further analysis.
It may also be necessary to retain entire organs for a more detailed examination. This is strictly limited to cases where retention is necessary to determine or confirm the cause of death.
These organs are retained until the pathologist indicates that all necessary tests have been completed. This may take a few days to several weeks after the initial post-mortem. In a very small number of cases it may take several months.
If an organ(s) is retained the Social Worker in the Coroner's Office will contact the next of kin as soon as possible to discuss options available to the family.
If the family is advised that organs have been retained, it is important that the family discuss these matters with the funeral director prior to finalising funeral arrangements. The funeral director will assist the family in making all necessary arrangements for the collection, and burial or cremation of retained organs.
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A copy of the post mortem report can be made available to the senior next of kin. If you are not the senior next of kin, then the views of the senior next of kin are sought before the post mortem report is released.
If you are the senior next of kin and wish to receive a copy of the report
, write to the Manager, State Coroner’s Office, 302 King William Street, Adelaide South Australia 5000. The letter should state your name and your relationship to the deceased. Also include the name and address of the doctor to whom you would like the report sent.- top -
Many people wish to see the body of a loved one as soon as possible after death. To assist this to happen the State Coroner makes every effort to release the body as soon as possible.
Wherever possible, it is suggested that any viewing be arranged with the funeral director as their facilities are usually much more suitable. However, the State Coroner may, in certain circumstances, allow a viewing of the body before release. If you have a specific request please contact the Social Worker at the State Coroner’s Office on (08) 8204 0600.
A viewing is done by prior arrangement and is conducted during limited hours Monday to Friday.
A viewing should not be confused with a formal identification of the body arranged by the police.
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Once the State Coroner has received the report outlining the cause of death, the next of kin will be formally notified of the official cause of death. The next of kin will also be notified when a decision is made whether or not an inquest is necessary or desirable.
The pathologist performing the post-mortem provides initial information to the State Coroner immediately after the post-mortem. This is called the provisional cause of death.
Next of kin will receive a letter stating the provisional case of death.
Once the State Coroner makes a finding if you want to view documents relating to an investigation, you should speak or write to the Social Worker at the State Coroner’s Office. The telephone number is (08) 82040600.
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An approach to a funeral director should be made as soon as possible. The funeral director will liaise with the State Coroner’s Office regarding the release of the body.
The body cannot be released until the post-mortem is complete and the body has been formally identified. In a small number of cases there may be a delay in release, usually associated with difficulties in identification or related to the collection of evidence.
If organs have been retained for further testing this should be taken into account when deciding the date of the funeral.
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If you believe that you are unable to finance the funeral, you should enquire about the Funeral Assistance Program run by Department for Communities and Social Inclusion (DCSI).
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Yes. If a body needs to be transported interstate or overseas arrangements should be made with a funeral director to prepare the body and the necessary documentation. The funeral director will also advise on the relative cost of transporting the body compared with a cremation and subsequent transport of the ashes of the deceased.
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If a person dies in hospital, or is dead on arrival at a hospital, then that hospital will be responsible for personal items. Similarly, if the death occurs in an institution, property will remain with the institution for collection by next of kin.
If a person dies at home, personal items will either be handed to relatives by the police or taken for safe keeping to the local police station. If personal items are found when the body is admitted to the City Mortuary they will be sent for safe keeping to the Adelaide Police Station.
If the deceased is admitted to the City Mortuary the clothing is generally handed over to the funeral director. However, if the clothing is contaminated in any way it will be disposed of immediately. This is for occupational health and safety reasons.
Generally valuables and clothing may be collected by the next of kin. However, if any of these items are required as evidence they will not be available until the police and the State Coroner have concluded their investigations.
Disputes over the ownership of valuables or any other property is not a coronial matter, and therefore coronial staff are not permitted to become involved. Such matters should be referred to the executor of the estate, and if there is no will, the Public Trustee.
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Once the State Coroner makes a finding and advises the Registrar of Births, Deaths and Marriages the Registrar will, upon application and payment of a fee, provide you with a full death certificate.
The Office of Births, Deaths and Marriages is located on the 2nd Floor, Chesser House, 91 Grenfell Street, Adelaide. You can contact them on 131 882.
Before making an application to receive the death certificate from the Births, Deaths and Marriages Office, check with the funeral director to ensure that they have not already made the application on your behalf.
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Every case is different and so the time taken to investigate cases varies greatly. Next of kin are advised in writing once a finding is made, or if the decision is made to hold an inquest.
The State Coroner's Office does not usually release detailed information about the circumstances of death until a finding has been made. To do so may compromise the investigation or provide incomplete and therefore misleading information to the next of kin.
Once a finding has been made, if you wish to view documents relating to the circumstances, please write to the Social Worker at the State Coroner's Office.
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An inquest is a court hearing in which the Court gathers information to assist in determining the cause and circumstances of death and if appropriate, to make recommendations that may prevent similar deaths occurring in the future.
The Court calls witnesses to give evidence of what they know about the death. An inquest is not a trial, rather it is an investigative process to shed light on the cause and circumstances of a death.
The Coroner’s Court is less formal than other Courts. It is not bound by the laws of evidence and is not too technical or legalistic. In making a decision the Court can also make recommendations to any relevant authorities that may result in changes to laws or practices in order to prevent similar deaths in the future.
It is not the Court’s role to establish whether a crime has been committed or to find a person guilty of that crime. Nor is it the Court’s role to make judgments about matters of civil liability.
Inquests are generally open to the public.
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When satisfied on consideration of the material produced from the investigation (statements of witnesses and medical reports) as to the cause and circumstances of death, the State Coroner may decide not to hold an inquest. Few deaths reported to the State Coroner become the subject of an inquest.
However, if the State Coroner believes that the cause or circumstances of death are a matter of substantial public importance particularly if they relate to public health or safety, he may decide to hold an inquest.
Inquests must be conducted where death has occurred in custody. This means a person in custody of the police, a person in prison or home detention, or a person under a detention order as a result of a mental or intellectual disability.
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A relative of a person whom the State Coroner decides has a sufficient interest in the matter may request an inquest. The request must be in writing to the State Coroner and must state the reasons for the request.
The State Coroner will consider those reasons when deciding whether or not to hold an inquest.
Next of kin will be informed of the State Coroner's decision.
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The next of kin listed by the State Coroner's Office will be advised in writing of the time and place of the hearing, if it is decided to hold an inquest.
After the inquest is completed, a copy of the Court’s findings and any recommendations will be sent to the next of kin.
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Normally any person may attend and listen to the court proceedings. In certain circumstances, the Coroner may exclude individuals or the public generally, or prohibit the publication of evidence.
Next of kin are not required to attend an inquest unless they are being called as witnesses.
Attending an inquest can be unnerving or even traumatic for families, both because of the content of the evidence and being unfamiliar with the courtroom process.
If you are represented by a lawyer, that person should prepare you for the inquest and provide support. If you are not represented, you may wish to contact the Social Worker in the Coroner's Office who can provide information and help prepare you for your attendance at the court. The telephone number is (08) 8204 0600.
You may bring friends to Court for support.
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No, but next of kin may choose to be represented by a lawyer.
Any person who, in the opinion of the State Coroner, has a sufficient interest in the subject matter of the inquest may either apply to the State Coroner for leave to appear in person to ask questions or be legally represented.
If you are asked to give evidence at an inquest, you can contact the Coroner's Court to find out what you need to do. The telephone number is (08) 8204 0600. It may be useful to attend another inquest to see what happens.
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It is part of the State Coroner's role to ensure that all relevant aspects of a matter are investigated, and that next of kin are given efficient service and treated with sensitivity. If you are not satisfied with any aspect of the coronial process, you may raise your concerns with the State Coroner in writing. The State Coroner will consider any concerns that you may have.
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A counselling, information, and support service is provided by experienced Social Workers and you are invited to use this service, either by telephone or by appointment in person. This service includes:
initial grief and crisis counselling during the time immediately following the death;
counselling at key points following the death, for example when a finding is made;
in appropriate circumstances, assistance to view the body of the deceased;
provision of specific information about the coronial process;
help in preparing for inquests;
information about bereavement support groups;
information on helping children to understand death;
referral to longer term counselling and other resources;
community education about the State Coroner's Office, and related matters.
These services are free of charge and any family member or friend may use them by phoning (08) 8204 0600 during office hours. The Coroner’s Office website at www.courts.sa.gov.au has many links to specific grief counselling services.
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Court and other records are generally available for inspection or copying. Some material, for example material that has been suppressed from publication by the Court requires the permission of the State Coroner before it can be inspected or copied.
A fee may be charged for inspecting or copying documents. It is necessary for an appointment to be made to allow for the inspection or copying of records.
Enquiries regarding access to records can be by telephone on (08) 8204 0600, in writing or in person at the Court Registry or by email on coroner@courts.sa.gov.au.
302
King William Street
Adelaide SA 5000
DX Box 668 Adelaide
Telephone:
+61 8 8204 0600
Facsimile: +61 8 8204 0633
Email: coroner@courts.sa.gov.au
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