Inquests

An inquest is a court hearing conducted by the coroner to gather information about the cause and circumstances of a death. An inquest isn’t a trial and there is no jury. It’s 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 don’t apply, the coroner must conduct proceedings fairly.

The coroner hears evidence on oath from people who have information about the death, including police officers, family members, doctors, other experts, eyewitnesses or the public.

If there is an inquest, coroners can make recommendations about matters connected with the death—such as public health and safety matters or the administration of justice—to prevent similar deaths in the future.

The inquest is usually held in the Magistrates Court closest to where the death occurred.

When an inquest is held

Very few coronial investigations proceed to inquest. An inquest must be held if the:

  • death occurred in custody
  • death occurred while the person was in care and there are issues about the care
  • death occurred as a result of police operations unless the coroner considers an inquest isn’t needed
  • attorney-general directs that an inquest be held
  • state coroner orders an inquest to be held
  • District Court upholds an appeal against a coroner’s decision not to hold an inquest.

A coroner may also hold an inquest if it’s in the public interest to do so. They may decide there is significant doubt about the cause and circumstances of death, or believe an inquest may prevent future deaths or uncover systemic issues that affect public health and safety.

Once the coroner has decided the inquest hearing date, the coroner’s staff tell the family when the inquest will begin. A notice about the inquest is also published in the law list in The Courier-Mail (online version only) and posted on the website.

Inquest duration

The length of an inquest depends on the complexity of the case, and the number of witnesses and parties. Often the length of time is estimated at the pre-inquest conference.

Who attends an inquest

Inquests are usually open to the public, though sometimes a coroner may exclude certain people or the public from the inquest hearing. A coroner can also prohibit the publication of evidence heard at inquest.

Family members need not attend unless they’re a witness. The evidence may distress families, as medical evidence and personal information about their loved one is discussed openly.

You may wish to bring a friend for support during the inquest. Counsellors from Coronial Family Services can also help families understand and prepare themselves for the inquest.

What happens at an inquest

  1. The counsel assisting and other parties introduce themselves.
  2. The witnesses are called to give evidence on oath.
  3. Each party asks questions in turn. Sometimes the coroner also asks questions.
  4. After all the witnesses have been heard, the evidence is closed.
  5. The parties make final submissions to the coroner.
  6. The coroner usually adjourns the hearing for time to consider the evidence and write their findings (about the identity of the deceased, and when, where and how they died).
  7. Sometimes the coroner makes and delivers their findings the same day. Usually, they adjourn to a future date.
  8. Later the parties are invited back to hear the coroner deliver the findings.

Pre-inquest conference

Once the coroner decides hold an inquest, they usually hold a pre-inquest conference to prepare matters for the inquest. A pre-inquest conference is not the hearing itself.

At the pre-inquest conference, the coroner decides what issues to consider, who the parties are, what evidence will be called, how long the inquest will take and where to hold it.

Counsel assisting the coroner outlines the issues to be considered. The parties may make submissions about issues they think should be included.

If a family isn’t legally represented, counsel assisting discusses the issues with them before the pre-inquest conference and any concerns they have.

Requesting an inquest

Request an inquest by writing to the coroner outlining why it’s in the public interest. The coroner must make the decision within six months, though they may extend that time if they’re waiting on information from a third person.

The coroner must give written reasons for their decision. If the coroner refuses your request, you may apply to the state coroner or the District Court for an inquest within 14 days of receiving the coroner’s reasons.

Legal representation

Anyone with sufficient interest can apply to participate in the inquest (i.e. ask questions of witnesses and make submissions). Parties may act for themselves or have legal representation.

Discuss legal representation with the lawyer assisting at inquest (‘counsel assisting’) whose role is to ensure all relevant information is presented to the coroner. Although they’re independent and don’t act for the family, they can explain the process and issues to be explored.

You can seek independent legal advice from:

Being a witness

It may be necessary for police to take a statement from you about information you have about the death. Find out more about being a witness.