Coronial Inquests

Coronial Inquests

Coronial inquests are public hearings held to examine the cause and circumstances surrounding the death of somebody in unusual or unnatural circumstances.  Inquests are conducted by magistrates in their role as coroners.

Not all deaths are the subject of a coronial inquest.  In many instances where a person’s cause of death is obvious and uncontroversial, there will be no inquest held.  Coroners examine reports submitted by police in respect of each death and determine which need to be further investigated.  The family of a deceased person can request a coroner to investigate the death of their loved one, although it is ultimately a decision for the coroner as to which deaths require an investigation and inquest.

There are certain deaths which by law must be the subject of an investigation and inquest.  These include:

  1. All deaths in police or prison custody, or the result of a police operation; and
  2. Some deaths in care (i.e. those involving mental health facilities or nursing homes for the disabled etc) where there is concern about the deceased person’s care.

Inquests for deaths in custody must be conducted by the State Coroner (based in Brisbane) or the Deputy State Coroner.  Other deaths can be handled by local magistrates throughout Queensland, although all coronial matters are administered and overseen by the State Coroner.

Coroners have specific powers to assist them in investigating deaths.  They have a power of entry at particular scenes and can direct police officers to conduct certain investigations on their behalf.

Coroners can order post mortems, and even exhumations of bodies that have already been buried.  They can also obtain expert reports from qualified professionals in a particular field, and may subpoena documents and require witnesses to attend at court to give evidence on oath.

After an investigation is complete (usually by the police on a coroner’s behalf) a coroner then decides whether or not an inquest should be held.  In making this decision the coroner will take into account the wishes of the deceased’s family and any other interested parties.

If the coroner decides to hold an inquest, this will usually commence with a “pre-inquest conference” which is a brief administrative hearing where all of the parties with a relevant “interest” come together for the coroner to make orders and arrangements for holding the inquest.  Issues such as when and where the inquest will be held, which parties will be allowed to appear and take part in the inquest, and what witnesses will be questioned, are determined at this point in time.

The actual inquest usually then commences some weeks or months later.  Any party that has a direct legal interest in the outcome of the inquiry is likely to be given leave (permission) to appear.  The coroner will usually be assisted at the inquest by a police prosecutor or another lawyer.  That person will act as “counsel assisting” and be primarily responsible for questioning witnesses on oath.  Prior to an inquest commencing, witnesses will usually have completed a statement which is formally tendered to the court at the inquest.  Each witness can then be questioned about their statement, firstly by counsel assisting the coroner.  Other parties that have been given leave by the coroner to appear at the inquest can also then question the witnesses.

At the conclusion of the inquest the coroner must deliver findings in which s/he establishes, if possible, who the deceased was, when and where the deceased died and how they died.

Coronial inquests also involve two other important functions.  The first is the coroner’s power to make recommendations.  Part of the coroner’s duty is to consider from the evidence whether any recommendations or opinions should be publicly expressed with a view to avoiding similar deaths occurring in the future.

Another function of the coronial inquest is for the coroner to determine whether there is a reasonable suspicion that someone has committed an offence of some sort.  A coroner may suspect that someone is responsible for the person’s death, for example due to murder, manslaughter or dangerous operation of a vehicle.  If the coroner reasonably suspects such involvement, the coroner has a duty to refer information gathered during an investigation (and inquest) to the relevant agency, commonly the Director of Public Prosecutions.  The coroner does not personally express a view about possible guilt, but simply refers the information to the proper government agency for a decision to be made by that other body.