Coronial investigations

Deaths are usually reported to the coroner by the police who attend the scene of a death (or by a medical practitioner i.e. in a hospital).

Once a death is reported, the coroner investigates 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 generally help the coroner gather evidence.

Many of the below steps happen within a few days. However, a coronial investigation may take several months to be finalised. As every case is different the time to finalise can vary. The length of time depends on the case’s unique circumstances.

These are the basic steps of a coronial investigation:

  1. The death is reported to the coroner, usually by police who attend the scene and get initial information about the death from family members, friends and witnesses. The coroner is notified of the death by a police report (Form 1) or medical professional (Form1A).
  2. The deceased is transported to a mortuary - police arrange for the government-contracted funeral director to take the deceased to a mortuary.
  3. The coroner orders an autopsy (if necessary) to help determine how and why the person died. The coroner considers family and cultural concerns before ordering an internal autopsy.
  4. Family may be contacted by Coronial Family Services – counsellors may contact you about the death and autopsy process.
  5. Family will be notified by the coroner - the senior next of kin will be advised by the coroner that the death is being investigated. Family will be updated throughout the investigation by a case manager.
  6. The deceased is released for burial or cremation – once the autopsy is complete and the body no longer needs to be kept for further examination or tests, it will be released into the care of the family’s funeral director. This usually occurs within 3-5 days. The coroner has the deceased person formally identified before releasing them to the family for the funeral. Police usually rely on a visual identification by someone who knows the person well. However, if that’s not possible, they use fingerprint, dental or DNA identification.
  7. Police help the coroner investigate the death – after reviewing the initial report of death the coroner may ask police to investigate further, possibly including getting medical records and further statements from witnesses. The coroner has wide powers of investigation, and can request additional reports, statements or information about the death. They may obtain more information from investigators, police, doctors, engineers, workplace health and safety inspectors, mining inspectors, air safety officers, electrical inspectors and other witnesses.
  8. Coroner completes their enquiries - once the coroner has completed their enquiries, they consider whether to hold an inquest (public hearing) into the death. The coroner consults with the family, who can also make a request for the coroner to hold an inquest.
  9. Coroner makes written findings - at the end of the investigation, the coroner makes written findings and sends a copy to the family. Most coronial investigations are finalised without an inquest.