Coroner and inquests

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.