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The coroner makes written findings, where possible, about the identity of the deceased; when, where and how they died; and what caused them to die.
At an inquest, the coroner may also make recommendations about broader issues connected with the death to prevent similar deaths in the future. For example, the coroner may recommend improving hospital procedures, safety standards or road signage.
During the inquest the coroner can receive expert evidence on which to base such recommendations.
What the coroner can and can’t do
The coroner can’t make any finding that a person is guilty of an offence or civilly liable. Additionally, their findings and recommendations can’t be used as evidence in any court or tribunal because the focus (of the Coroners Court Act 2003) is helping prevent further deaths in similar circumstances.
However, the coroner can refer a matter to the Director of Public Prosecutions or a disciplinary body for consideration and possible action.
Where findings are published
Findings are provided to the family. If recommendations are made, they’re sent to the responsible government department.
If an inquest has been held, the findings are posted on the website unless the coroner orders otherwise. The coroner can publish non-inquest findings on the website if it’s in the public interest (though they must consult with the family before doing so).
Reopening investigations and inquests
The matter is finalised once a coroner has made their findings. However the coroner may reopen an investigation or inquest in rare cases where new evidence has been found or the circumstances require more investigation.
Disagreeing with findings
If you’re dissatisfied with inquest findings, you can apply to the state coroner or District Court to have the findings set aside. Submit Form 21 - Application to the State Coroner to set aside a finding or .
The state coroner or the District Court can set aside the finding and direct that the inquest be reopened or a new inquest held.
The state coroner may set aside a finding if new evidence casts doubt on the findings or they weren’t recorded correctly.
The District Court has wider jurisdiction and may set aside a finding if:
- new evidence casts doubt on the findings
- the findings were not recorded correctly
- there was no evidence to support the finding
- the evidence couldn’t reasonably support the finding.