What is an inquest

An inquest is a formal court investigation into a death. In the Northern Territory (NT), inquests are usually held in Local Court courtrooms in Darwin, Alice Springs or Katherine.

An inquest can run for one day, several days or sometimes longer.

Mandatory inquests

A coroner must hold an inquest if the death was a death in custody or a death in care.

For more information, go to reportable deaths.

Discretionary inquests

For all other reportable deaths, the coroner decides whether an inquest should be held.

The coroner considers things such as:

concerns raised by the family
whether the circumstances are clear, uncertain or based on conflicting evidence
whether someone may have caused or failed to prevent the death
whether an inquest could help identify broader issues that support public health or prevent future deaths
whether an inquest could uncover more evidence
whether an inquest would help maintain public confidence in justice, health services or other agencies
whether there have been similar deaths (a cluster).

Who attends an inquest

The family and other interested people or organisations are notified. The coroner decides who may attend.

Common attendees include:

counsel assisting – a lawyer chosen by the coroner to help manage the investigation, evidence, witnesses and submissions
family members – they can speak with Counsel Assisting or have their own lawyer
agencies involved in the person’s care or custody – for example, Police, Correctional Services, the Department of Children and Families, or the Department of Health
other relevant agencies or individuals – such as Housing, Local Government, an NDIS provider, a clinic, a school, or other witnesses
interpreters, if needed
the coroner’s grief counsellor, if available
members of the public
media.

Lawyers representing families or agencies are not paid by the coroner’s office. They must arrange and pay for their own legal support.

Anyone may sit in the courtroom unless the coroner closes part of the hearing or restricts what the media can report.

What is investigated

An inquest looks at the circumstances of the death, including:

who died
when and where the person died
the cause of death
any circumstances relevant to the death
issues linked to public health, safety, or the justice system
for deaths in custody – the care, supervision and treatment provided
how future deaths in similar circumstances might be prevented.

The coroner doesn't decide criminal or civil guilt. However, if the coroner believes an offence may have been committed, they can report this to police or the Director of Public Prosecutions.

What happens during an inquest

Counsel assisting will present the brief of evidence, identify witnesses and question them. More evidence or witnesses may be added during the inquest.

Sometimes the coroner and lawyers visit the location where the death occurred.

Lawyers for the family or other parties may also question witnesses and present evidence.

The brief of evidence may include:

autopsy and medical records
witness statements
expert reports
photos, CCTV or body‑worn video
relevant documents such as policies and procedures
agency or organisational responses.

After all evidence is heard, lawyers make submissions. They summarise the evidence and may suggest findings or recommendations for the coroner.

Courtroom rules

When attending an inquest, you should:

bow to the coroner when entering or leaving the courtroom
enter and exit quietly
not talk, eat or chew gum
turn off your mobile phone
remove hats and sunglasses, including from the top of your head.

The coroner wants people to feel comfortable. If you are unsure about anything, you may ask:

counsel assisting
a court officer
your lawyer
grief counsellor.

If you are deaf or hard of hearing, tell the court officer. If available, a hearing aid can be provided.

Witnesses

Some witnesses receive a summons and must attend. They should contact the coroner’s office or counsel assisting to discuss arrangements. If travel is difficult, witnesses may sometimes give evidence by video.

A witness who is summoned and doesn't attend or give evidence as instructed may be arrested.

For more information, read about being a witness in an inquest.

After the inquest

Once the inquest ends, the coroner reviews all the evidence and prepares written findings. This can take weeks or months depending on the complexity of the case.

The senior next of kin will be told when the findings are ready. Sometimes the coroner reads the findings in court, but more often they are released electronically.