Coronial findings

After the completion of an investigation, and inquest if held, the coroner makes written findings.

There are 2 types of coronial findings:

• inquest findings - made after an inquest.
• chamber findings – made after an investigation when no inquest is held.

Most deaths are resolved with chamber findings. Less than 3% of reported deaths go to inquest.

Coronial findings explain:

• who the deceased person was
• when and where they died
• the cause of death
• the circumstances related to the death
• the care, supervision or treatment of a person in custody, or a person whose death was caused or contributed to by injuries while in custody
• any other matters connected to the death, including issues about public health, safety or justice
• any recommendations the coroner chooses to make.

Coroner recommendations

The coroner may recommend broader changes to the Attorney-General. These may relate to:

• preventing similar deaths in the future, such as improving hospital procedures, safety standards or road signage
• matters involving public health, safety or the administration of justice.

What the coroner can and can't do

The coroner can't:

• decide who is criminally or civilly liable for a death
• say that a person is or may be guilty of an offence.

The coroner can:

• refer a matter to the Director of Public Prosecutions or the Police Commissioner if the coroner believes an offence may have been committed
• refer findings to an investigative or disciplinary body, such as WorkSafe, the Health and Community Services Complaints Commission or the Australian Health Practitioner Regulation Agency (AHPRA).

Decision not to hold an inquest

If the coroner decides not to hold an inquest and issues chamber findings, they must notify the senior next of kin (or another person) in writing.

That person then has 14 days to apply to the Supreme Court for an order requiring an inquest. The Supreme Court may order an inquest if it considers it appropriate - section 16, Coroners Act 1993.

Where findings are published

Findings are given to the family and any other people the coroner considers relevant.

If the coroner makes recommendations, the findings are sent to the Attorney-General.

Inquest findings

Inquest findings are published on the website unless the coroner orders otherwise.

Go to inquest findings.

Chamber findings

Chamber findings are usually provided only to the next of kin. They may be published if it is in the public interest or if recommendations are made.

Re-opening investigations and inquests

A coronial investigation is finished once the coroner makes findings.

In rare cases, an investigation or inquest can be re-opened if new facts or evidence are found, section 44A, Coroners Act 1993.

A person may also apply to the Supreme Court to declare some or all of the findings void. The Court may:

• declare findings void
• order a new inquest or re-open the inquest, section 44, Coroners Act 1993.