Once a death is reported, the coroner must investigate the circumstances of the death to establish:
- the identity of the deceased
- when and where they died
- how they died
- the medical cause of death.
The coroner controls and coordinates each step of the investigation. Police officers assist the coroner to gather evidence.
A coronial investigation may take several months. The length of the investigation will depend on the unique circumstances of the case.
The steps of a coronial investigation
Step 1 - The death is reported to the coroner, usually by police who will have attended the scene and obtained some initial information about the death from family members, friends and witnesses.
Step 2 - Police arrange for the government contracted funeral director to take the deceased to a mortuary.
Step 3 - The coroner requires the deceased person to be formally identified before they can be released to the family for the funeral. Police will usually rely on a visual identification by someone who knows the person well. If this is not possible police may use other options such as fingerprint, dental or DNA identification.
Step 4 - Police assist the coroner to investigate the death and will prepare an initial report (called a Form 1) for the coroner. After considering the initial report the coroner may ask police to conduct further investigations which may include obtaining medical records and taking further statements from witnesses.
Step 5 - In most cases, the coroner will order an autopsy to be conducted to help find out how and why the person died. Family and cultural concerns are considered before ordering an internal autopsy.
Step 6 - Once the autopsy is complete and the coroner is satisfied that it is not necessary to retain the body for further examination or tests, the deceased can be released for the family for burial or cremation.
Step 7 - The coroner has wide powers of investigation and can request additional reports, statements or information about the death. Additional information may be obtained from investigators, police, doctors, engineers, workplace health and safety inspectors, mining inspectors, air safety officers, electrical inspectors or other witnesses.
Step 8 - Once the coroner has completed these enquiries they will consider whether to hold an inquest into the death. The coroner will consult with the family about whether an inquest is to be held. Families can also request the coroner to hold an inquest.
Step 9 - At the end of the investigation the coroner must make written findings. A copy is sent to the family. If an inquest is held, the findings may be very lengthy.