The State Coroner 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 State Coroner’s role to establish whether a crime has been committed or to find a person guilty of that crime. Nor is it the State Coroner’s role to make judgments about matters of civil liability.

Inquests are generally open to the public.

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. Only a small percentage of all deaths reported to the State Coroner are 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 a person under a detention order as a result of a mental or intellectual disability.

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 Coroner’s decision.

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.

In addition, next of kin, and other persons at the discretion of the State Coroner, may access all written evidence prior to the inquest. If you have legal representation at the inquest, this may be arranged through your lawyer. Those who are not represented by a lawyer, should contact the Social Worker in the Coroner’s Office

After the inquest is completed, a copy of the Coroner’s findings will be sent to the next of kin.

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 being 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.

You may bring friends to court for support.

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 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. It may be useful to attend another inquest to see what happens.

If you are not satisfied with part of the coronial process, you may raise your concerns with the State Coroner in writing.

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. He will consider any concerns that you may have.