Overview of the Coronial process

Investigation Process and Overview

Police, medical, health and emergency professionals have a statutory obligation to report sudden and or unexplained deaths to the Coroner. This is where the coronial process begins.

The vast majority of coronial matters – around 98% - are resolved without the need for a court hearing.

Every coronial investigation is unique and it is up to the Coroner to decide what kind of investigation is necessary. It may involve:

• a review of the person's medical history and the circumstances of the death
• a post mortem and pathology tests
• specialist reports from experts and external investigators such as police, doctors, engineers and the fire brigade
• statements from witnesses, including family and friends
•  A combination of the above

The Coroner’s role is to find out the identity of the deceased person (if required) and the date, place, medical cause and circumstances of their death. This will usually involve a number of investigations being carried out on the Coroner’s behalf.

Family may provide any information they believe the Coroner should be aware of in relation to the death of their loved one at any time by writing or emailing the court.

How long does a Coroner's investigation take?

The length of time to investigate a death differs substantially from case to case and depends on the nature of the death, the number of factual inquiries and medical examinations or tests involved, and the complexity of the matter.  Whilst some cases may be resolved within a few months, others take more time -  up to twelve months and in some instances, even longer.

Unfortunately, a number of popular television shows perpetuate the myth that a cause of death can be established quickly and that the Coroner can pinpoint the time of death precisely. Neither of these things is true. The reality is that a coronial investigation is both complex and lengthy. Whilst some cases may be resolved within a few months, most cases can take considerably longer.

If, at the conclusion of this investigation, the cause or manner of death remains unclear, the Coroner will usually direct that an inquest or court hearing be conducted.

Will a court hearing definitely take place?

Not necessarily.

After reviewing evidence from police and all other information, the Coroner will decide if an inquest or court hearing is needed. Most coronial proceedings can be finalised by the Coroner without the need for an inquest. In cases where the cause and manner of death are clear, the Coroner will usually finalise the matter without holding an inquest.

It is important to note that only a small number of matters reported to the Coroner  - less than 100 of the 8000 reported annually - proceed to a court hearing. The vast majority are finalised by the Coroner based on documentary evidence received during the investigation and a court hearing is not required.

When the decision on whether or not to hold a court hearing has been made by the Coroner, family are informed in writing.

Inquest and Inquiries - differences explained

What if there is evidence that a criminal offence was committed?

In some cases, the investigation leads to the discovery of evidence that results in a person or persons being charged with indictable offences in connection with the death.  

The Coroner’s court has no jurisdiction to deal with criminal offences so, in these cases, the Coroner must suspend the coronial proceedings until the criminal prosecution is concluded. 

What happens once the investigation is complete?

Once the investigation is complete, the Coroner will review all of the evidence that has been gathered in order to determine whether an inquest (a court hearing to explore any unresolved issues)  is necessary. In making this decision, the Coroner will also take into account the wishes of the family of the deceased person.

Most coronial proceedings can be finalised by the Coroner without the need for an inquest. In cases where the cause and manner of death are clear, the Coroner will usually dispense with the need for an inquest and finalise the matter.

The next of kin and other interested parties will receive a letter telling them that the case is finalised and what the Coroner has determined as the cause and manner of death.  If you wish to receive reasons for the Coroner's decision to dispense with an inquest, you should submit a written request to the court by post or email.

If, at the conclusion of the investigation, the cause or manner of death remains unclear, the Coroner will usually direct that an inquest be conducted. 

Missing persons, whom police suspect may be deceased, are also reported to the Coroner and investigated.  An inquest is required to be held in all missing person cases.  Read about support services available to friends and relatives of missing persons

Access to evidence gathered during the coronial investigation

If you have a appropriate interest in a coronial matter and seek access to evidence gathered during the investigation please complete the Application for Access to Coronial Documents​ (PDF, 112.1 KB) form.