What is an inquest?
The Coroners Act 2003 provides for the investigation of certain deaths by coroners and outlines procedures for the holding of inquests.
An inquest is a court hearing conducted by the coroner to gather more information about the cause and circumstances of a death. Coroners can also make recommendations about matters connected with the death, including matters related to public health and safety or the administration of justice. These recommendations are aimed at preventing similar deaths in the future. Recommendations can only be made if an inquest is held.
An inquest is not a trial and there is no jury. It is not about deciding whether a person is guilty of an offence or civilly liable. Inquests are less formal than conventional court hearings and the coroner can inform themselves in any way they consider appropriate. Although the rules of evidence do not apply, the coroner must ensure that the proceedings are conducted fairly.
The coroner will hear evidence on oath from people who have information about the death. These witnesses can include police officers, family members, doctors, other experts, eye witnesses or members of the public.
The inquest is usually held in the closest magistrates court to where the death occurred.
When is an inquest held?
Very few coronial investigations proceed to inquest. An inquest must be held if:
- the death is a death in custody
- the death occurred while the person was in care and there are issues about the care being provided
- the death occurred as a result of police operations unless the coroner considers the circumstances do not require an inquest
- the Attorney-General directs that an inquest be held
- the state coroner orders an inquest to be held
- the District Court upholds an appeal against a coroner’s decision not to hold an inquest.
In other cases, a coroner may decide to hold an inquest if it is in the public interest to do so. In deciding this, the coroner may consider whether there is significant doubt about the cause and circumstances of death or whether holding an inquest may help to prevent future deaths or uncover systemic issues which affect public health and safety.
Can I request that an inquest be held?
You can request that an inquest be held by writing to the coroner outlining why you think it is in the public interest for an inquest to be held. The coroner must make the decision within six months. Sometimes the coroner may contact you to extend the time for the decision to be made. This might happen where the coroner is waiting on information from a third person that will help them make the decision.
The coroner must give written reasons for their decision. If the coroner refuses the request a further application can be made to the state coroner or the District Court for an inquest to be held. This application must be made within 14 days of receiving the reasons for the decision.
How will I know when the inquest is being held?
Once the coroner has decided the hearing date, the coroner’s staff will advise the family when the inquest is to begin. A notice about the inquest will also be published in the law list in The Courier-Mail and posted on the website.
Who can attend the inquest?
Inquests are generally open to the public so anybody can attend and listen to the proceedings. Sometimes a coroner may decide to exclude certain individuals or the public from the inquest hearing. A coroner can also prohibit the publication of evidence heard at inquest.
Family members are not required to attend the inquest unless they have been called as a witness. The evidence presented at the inquest can be very distressing for families because medical evidence and very personal information about a loved one is discussed in open court. You may wish to bring a friend to provide support to you during the inquest.
Counsellors from Coronial Family Services can provide information to families to help them understand and prepare themselves for what might happen at the inquest.
Does the family need to be legally represented?
Any person with a sufficient interest (including family members) can apply to the coroner to participate in the inquest. This means you can be given permission to ask questions of witnesses and make submissions at the inquest. Parties can act for themselves and ask questions or they can be legally represented.
Family members may choose to be legally represented and may wish to discuss this with the lawyer assisting the coroner at inquest (called counsel assisting). The counsel assisting is an independent person whose role it is to ensure that all relevant information is presented to the coroner. Although they are independent and do not act for the family they will be able to explain the inquest process and the issues proposed to be explored at the inquest.
The family may wish to obtain independent legal advice about this issue. Free legal advice can be obtained from Legal Aid Queensland by calling 1300 651 188 or from a community legal centre (you can call the National Association of Community Legal Centres on (02) 9264 9595 or visit the NACLC website to find your nearest community legal centre).
Will I be required to be a witness?
It may be necessary for police to take a statement from you about information you have about the death. After reading your statement the coroner might decide that you need to attend the inquest to give further evidence. If you are required to give evidence then you will be notified about this in plenty of time. You can contact the coroner’s office if you are unsure about what you need to do. You may wish to seek legal advice from the organisations listed above.
How long will the inquest take?
The length of an inquest will vary depending on the complexity of the case, the number of witnesses and the number of parties. Often the length of time is estimated at the pre-inquest conference.
What is a pre-inquest conference?
Once the coroner has decided to hold an inquest the coroner will usually hold a pre-inquest conference. A pre-inquest conference is not the hearing, it allows for the preparation of matters for the inquest.
At the pre-inquest conference the coroner will make decisions about what issues will be looked at. Counsel assisting the coroner will outline the issues to be considered at the inquest. The parties may make submissions about other issues they think should be included. If a family is not legally represented then counsel assisting will discuss the issues with the family before the pre-inquest conference and consider any other concerns raised by the family. It is the role of counsel assisting to ensure that all relevant issues are presented to the coroner.
At the pre-inquest conference the coroner will also make decisions about who are the parties, what evidence will be called, how long the inquest will take and where the inquest will be held.
What happens at the inquest?
At the inquest counsel assisting and other parties will introduce themselves. The witnesses will be called to give evidence on oath. Each of the parties can ask questions in turn. Sometimes the coroner will also ask questions. After all of the witnesses have been heard, the evidence is closed. The parties then make their final submissions to the coroner. The coroner will normally adjourn the hearing to allow time to consider the evidence and write their findings. Sometimes, depending on the circumstances, the coroner will make their findings the same day. Usually the coroner will adjourn the hearing to a future date. The parties are then invited back to court to hear the coroner deliver the findings.
The coroner’s findings
The coroner is required to make written findings about the identity of the deceased and when, where and how they died and what caused them to die. When an inquest is held, the coroner may also make recommendations about broader issues connected with the death aimed at preventing similar deaths from occurring in the future. For example, the coroner might make recommendations about improving hospital procedures, safety standards or road signage. During the inquest the coroner can receive expert evidence on which to base such recommendations.
The coroner is prohibited under the Coroners Act 2003 from making any finding that a person is guilty of an offence or civilly liable for something and the coroner’s findings and recommendations cannot be used as evidence in any other court or tribunal. This is because the focus of the Act is to help to prevent further deaths from occurring in similar circumstances. However, the coroner is able to refer a matter to the Director of Public Prosecutions or to a disciplinary body for consideration and possible action by that body.
Findings are provided to the family and if recommendations are made they are sent to the responsible government department. The coroner’s findings are posted on the Queensland Courts website
If a person is dissatisfied with the findings they can apply to the state coroner or District Court to have the findings set aside.