Coroner and inquests

The coroner’s office investigates deaths and suspected deaths in the Northern Territory (NT) on behalf of the community.

The types of deaths the coroner will investigate are called reportable deaths.

As well as deaths, the coroner may inquire into disasters where public safety is substantially endangered.

The coroner decides whether or not to hold a public inquest into death – this is a public court hearing.

Decisions are available to the public. They are published on the Coroner’s decision page on the Department of the Attorney General and Justice website.

What is a reportable death

A reportable death means the death may be any of the following:

• appears to have been unexpected, unnatural or violent
• appears to have resulted, directly or indirectly from an accident or injury
• occurred during an anaesthetic or as a result of an anaesthetic and is not due to natural causes
• occurred when a person was held in, or immediately before death, was held in care or custody
• was caused or contributed to by injuries sustained while the person was held in custody
• of a person whose identity is unknown
• in certain other circumstances.

Report a death to the coroner

Usually a police officer or medical practitioner will notify the coroner of any reportable death.

Every person has a duty to do so if they believe the coroner may not have been informed.

If you don’t provide information about a death you could be charged with a criminal offence.

When a death is reported to the coroner’s office there are several steps that happen.

These are:

1. Informing the senior next of kin (family member) that the death has been reported to the coroner.
2. An autopsy of the person’s body if necessary.
3. A decision on whether or not to hold an inquest.

1. Next of kin informed death has been reported

The first step is that the senior next of kin will be told that the death has been reported to the coroner.

The senior next of kin can be any of the following:

• the person's husband, wife or de facto partner
• the person's son or daughter aged over 18 - if the person wasn’t married or their spouse isn’t available
• the person's parent - if their spouse, son or daughter is not available
• the person's brother or sister aged over 18 - where a spouse, son daughter or parent is not available
• a person who, according to Indigenous customs and tradition of their community or group, is an appropriate person.

2. When an autopsy of a person’s body is ordered

An autopsy is a medical inspection of the body to help find what caused the person’s death.

It is done by a Forensic Pathologist.

The autopsy can sometimes provide evidence of both:

• disease in the body
• and/or damage to the body.

The autopsy may take samples of blood and tissue from a person’s body.

In some cases, organs may have to be taken out of a person’s body for special testing.

If this is necessary the coroner’s office will tell the senior next of kin (family member).

When the next of kin doesn’t want an autopsy

If the senior next of kin does not want an autopsy on the person’s body, the coroner will write to them about the reasons why an autopsy is needed.

Where possible, the autopsy will be delayed for 48 hours.

The senior next of kin may apply to the Supreme Court for the autopsy not to be performed.

When an autopsy report is released to the family

The autopsy report is usually not released to the family.

An autopsy report is complex and can be easily misinterpreted. This can cause distress for the family.

However, if the family writes to ask for a copy of the report, a copy may be given to the senior next of kin's doctor.

The doctor can then explain and discuss any complex medical information to the family.

The family will usually be given the results of the autopsy through the coroner’s findings.

3. Coroner decides whether to hold an inquest

Inquests must be held if the person has died in care or custody.

It can take several weeks or months for the coroner to decide whether they will hold an inquest into a person’s death. This is so they can look at all the police and medical reports.

If the coroner decides to hold an inquest into a person’s death, they will inform the senior next of kin.

Most other reportable deaths don’t result in an inquest if: 

• the person’s cause of death is known
• and any further investigation won’t provide any further evidence about their death.

If the coroner decides not to hold an inquest

The coroner will give the senior next a kin a copy of their decision about why they are not holding an inquest into their relative’s death.

This is known as Inquest Decided Unnecessary (IDU) findings.

It is important to remember that the coroner does not decide on issues of criminal liability or civil negligence that may be connected to a person’s death.

The coroner is not allowed to include any comment or statement that any person maybe guilty of an offence.

Asks for an inquest to be held as a family member

Family member can write to the coroner about the reasons why an inquest should be held.

If the coroner refuses the family’s application for an inquest to be held, they can apply to the Supreme Court within 14 days of receiving the coroner’s reasons.

An inquest is a court hearing.

In the Northern Territory (NT), it is usually held in court room in the Darwin or Alice Springs Local Court.

During an inquest, the coroner hears evidence from witnesses.

The inquest may run for a week or several weeks. It may even be spread over several months.

When an inquest is finished

The coroner will take time to write his decision, this is known as findings in legal terms. 

This can also be weeks or months depending on the amount of evidence.

Decisions are available to the public. They are published on the Coroner’s decision page on the Department of the Attorney General and Justice website.

The coroner’s decision is also referred to as the coroner’s findings or inquest findings.

Who attends an inquest

Coroner and lawyers

The coroner sits on the bench at the front of the courtroom, and lawyers sit facing them on another table.

The coroner can decide if the following lawyers can attend:

• a lawyer representing the coroner’s office and community – this person is called counsel assisting the coroner
• the family of the person who has died
• an organisation who had care of the person when they died
• an organisation who had custody of the person when they died
• another organisation or person connected to the circumstances of the death.

It is important to remember that a lawyer representing the family, another person or organisation is not paid for by the coroner and must be at their own cost.

Members of the public

Members of the public and family can sit in the chairs behind the lawyers. Anyone can sit in the courtroom and listen to the evidence.

In some cases, the coroner may ask people to leave the courtroom and stop some evidence from being published in the media.

Courtroom rules 

When attending an inquest you should do all of the following:

• bow to the coroner when entering and leaving a courtroom
• enter and leave the courtroom quietly
• not talk, eat or chew gum
• turn off  your mobile phone
• remove your sunglasses if they’re resting on the top of your head.

Find out more information about courtroom rules.  

Witnesses

Witnesses must attend the inquest if they are asked by the coroner. This is called a summons to appear.

If they don’t attend the inquest, they can be arrested by police.

For more information, go to being a witness in an inquest.

What an inquest investigates

The inquest will investigate to find out all of the following:

• the identity of the person who has died
• the time and place of death
• the cause of death
• any relevant circumstances concerning the death
• other matters connected to the death including public health, safety or the administration of justice.

It is important to remember that the coroner does not decide on issues of criminal liability or civil negligence that may be connected to a person’s death, but may refer it to the Director of Public Prosecutions or police.

The coroner is not allowed to include any comment or statement that any person maybe guilty of an offence.

What happens in an inquest

The coroner and lawyers will ask witnesses to give evidence about what they know about the person’s death.

Lawyers may also show exhibits for witnesses to give evidence about or comment on.

Exhibits may include any of the following:

• written records
• photos
• voice recordings
• video images.

After hearing evidence from all of the witnesses, the lawyers will then each give their summary of the inquest, this is known as submissions.

They also tell the courtroom what they think the coroner should include their decision, also known as findings.

The coroner then adjourns the inquest to a later date to write their decision. This can take a matter of weeks or months.

When the coroner gives their formal findings

The coroner can take weeks or months to give their decision, depending on the amount of evidence that was included in the inquest.

The senior next of kin will be told when the coroner is ready to give their decision.

Family members and anyone else can attend the courtroom on the day the coroner gives their decision.

Who can get a copy of the coroner’s decision?

The coroner will give the senior next a kin a copy of their decision.

Other people can ask for copy of the findings from the coroner’s office, and this will be made available if the coroner decides it is appropriate.

If you are asked to be a witness in an inquest you must attend the court hearing. This is called a summons to appear and is given to you by police.

You can be arrested if you don’t attend an inquest.

If you don’t live in the Northern Territory (NT) or you live in a remote area, it may be possible to give your evidence by video link or phone.

To request this you will have to call the coroner's clerk on (08) 8999 7770 as soon you receive your summons to appear at the inquest.

Financial help to attend an inquest

You can apply to be reimbursed for any financial loss you have experienced because you have to attend an inquest.

This includes expenses such as travel costs and lost wages.

Contact the coroner's clerk on (08) 8999 7770 before the inquest to find out what arrangements can be made.

What you should bring to an inquest

You should take any relevant documents about the case to the inquest.

You may be asked to read from documentation, so remember to bring your reading glasses if you need them.

When you arrive at court for an inquest

When you arrive at court, the lawyer assisting the coroner will speak with you. They are also called counsel assisting the coroner.

You may sit outside the courtroom until you are called inside by a court officer.

Sometimes many witnesses may be called and the length of time their evidence takes may be uncertain.

It is not always possible to be given an exact time that you will be called in court.

Speak to the counsel assisting the coroner as they may be able to tell you if there will be any delays and what approximate time you will be called into the courtroom.

Witnesses are also sometimes allowed to sit in the courtroom and listen to the hearing.

The counsel assisting the coroner will tell you whether you can sit in the courtroom or not.

When you enter the courtroom

When you walk into the courtroom, the court officer will ask you how you would like to be sworn in, this is also known as being affirmed.

‘Sworn in’ means you agree to tell the truth to the court.

You can choose to either:

• swear on the Bible – which means you say ‘so help me God’ after the court officer asks whether you promise to tell the truth
• give an affirmation – which means you say ‘I do’ after the court officer asks whether you promise to tell the truth.

Giving evidence in an inquest

You should do all of the following:

• stay relaxed and calm
• tell the coroner if you need a break
• listen carefully
• ask for an explanation if you do not understand a question or cannot hear a question
• speak clearly and slowly
• be careful not to leave anything out when giving your answer
• ask the coroner if you are unsure or need advice.

When you are finished your evidence, the coroner will tell you that you can leave the courtroom. You may be allowed to stay and listen to other witnesses if the coroner says so.

If the coroner decides they want you to come back and give more evidence, you will be asked to return to court to be a witness.

Witnesses are not informed when the coroner will give their decision. 

Counsel and family members are told and the findings are published on Department of Justice website.

A death certificate is issued after the coroner has issued their findings, or IDU (Inquest Decision Unnecessary).  

The coroner will give the findings to the Registrar of the Births, Deaths and Marriages.

Find out how to apply for a death certificate.

The family or senior next of kin should appoint a funeral director as soon as possible after a person has died.

You should contact the coroner's office to find out when the person’s body can be released.

Find out more information on arranging a burial or cremation.

Coroner’s Office
GPO Box 1281
Darwin NT 0801

Darwin Local Courts
Nichols Place
Corner of Cavanagh Street and Harry Chan Avenue
Darwin NT 0800

Phone: 08 8999 7770
Fax: 08 8999 5128
nt.coroner@nt.gov.au

A death known or suspected most likely to be from coronavirus (COVID-19) will generally not need to be reported to the coroner.

This is because the death is from a natural cause and the probable cause of death is known.

Doctors are encouraged to issue a cause of death certificate in these cases.

A coronavirus (COVID-19) death will only be reportable to the coroner if:

• the death is a death in custody or a death in care or
• the person died as a result of the care they received or did not receive, for example, a missed diagnosis or failure to treat coronavirus (COVID-19).

However, a coronavirus (COVID-19) death will not be reportable for failure to provide health care because of inadequate resourcing in the event of an overwhelming demand for critical care services provided clinical decision-making for the person is consistent with the Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines of 16 March 2020.

Read the guidelines on the ANZICS website.

More information

For general enquiries about reportable deaths, contact the Northern Territory Office of the Coroner during business hours on 08 8999 7770.