Coronial investigations

Deaths are usually report to the coroner by the police who attend the scene (or a medical practitioner).

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 help the coroner gather evidence.

A coronial investigation may take several months. 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.
  2. Police arrange for the government-contracted funeral director to take the deceased to a mortuary.
  3. 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.
  4. Police help the coroner investigate the death and prepare an initial report (a Form 1) for the coroner. After considering the initial report, the coroner may ask police to investigate further, possibly including getting medical records and further statements from witnesses.
  5. In most cases, the coroner orders an autopsy to help determine how and why the person died. They consider family and cultural concerns before ordering an internal autopsy.
  6. Once the autopsy is complete and the coroner doesn’t need to retain the body for further examination or tests, the deceased is released to the family for burial or cremation.
  7. 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. Once the coroner has completed their enquiries, they consider whether to hold an inquest into the death. The coroner consults with the family, who can also request the coroner an inquest.
  9. At the end of the investigation, the coroner makes written findings and sends a copy to the family. If an inquest is held, the findings may be lengthy.