About the coronial process
For more information about the coronial process, as well as answers to some commonly asked questions, please download our booklet: “Coroners Court - A guide for family and friends”
What is an inquest?
In the ACT, a coronial investigation is called an inquest. The inquest commences as soon as the matter is referred to the coroner. This is different to other States and Territories, where an inquest means a court hearing.
The coroner investigates certain deaths to find out how and why they happened, and to help prevent similar deaths happening in the future. To read more about post-mortem examinations conducted as part of a coronial inquest, visit our page on the Forensic Medicine Centre (FMC).
Not all deaths are investigated by the coroner. The types of death a coroner will investigate are determined by the Coroners Act 1997.
Coronial inquests will occur where:
- the circumstances of the death are unnatural, violent, suspicious, or unknown
- the death appears to be wholly or partly attributable to an operation or procedure
- the person had not been seen by a doctor in the 6 months before their death, or a doctor has not given a medical certificate certifying the cause of death
- the death was caused by an accident
- the death happened when the person was in custody or care.
In order for an ACT coroner to investigate a death, the death must have occurred in the ACT, or the person who died must have ordinarily resided in the ACT.
In an inquest the coroner must, if possible:
- determine the identity of the person who has died
- determine the cause of their death
- determine how the death occurred (the manner of death)
- identify matters related to the death that may be relevant to public safety, and make recommendations about those matters.
The court will obtain and review relevant records, and will rely on the post-mortem report and a report from the investigating police officer, which may be updated throughout the investigation. Sometimes the court will request statements from witnesses and commission expert reports.
All of this work is carried out by investigating police officers and the in-house legal team at the court, and usually the coroner can make findings at the end of this investigative process.
Less than 5% of deaths reported to the ACT Coroners Court will proceed to a hearing in court.
What is the scope of an inquest?
The coroner makes a decision about the scope of an inquest based on the type and extent of information that is required to make findings, as well as what might reasonably be needed to answer questions about the death that the family might have. An inquest can only consider matters which are likely to be related to the cause of death.
How long does an inquest take?
Each year hundreds of deaths are investigated by the coroner. The court understands that the coronial process can be difficult for families, and that the time the investigation can take can add to the grieving process. Every effort is taken to resolve matters in a timely manner, but the length of time to complete an inquest can vary.
While many inquests will be completed within 12 months or sooner, some investigations can take years to finalise. This can occur for several reasons. New evidence can come to light, further lines of inquiry may arise, expert opinion may need to be obtained, families may have additional questions that need to be investigated, and the coronial investigation may be paused while any related criminal matter is finalised.
Investigation by Police
The ACT Policing Coroners team is a small group of ACT Police who specialise in coronial matters. They assist the coroner with police investigations into deaths. This team reports the death to the coroner and liaises with investigating case officers.
These police officers are acting for, and under the control of, the coroner. The presence of police at a death scene does not mean that a criminal investigation is taking place.
What if there are criminal proceedings?
If a coroner is of the view that a criminal offence has been committed in connection with a death, the coroner must refer the matter to the Director of Public Prosecutions (DPP). This may be obvious in some cases, but in others it may only become evident as the investigation progresses.
When a matter is referred to the DPP, the coroner will cease all investigations into the death. The coroner will generally not investigate further until the matter is finalised by the DPP – either when the DPP advises that no criminal charges are to be laid, or after the conclusion of the criminal proceeding. A coroner must not make any finding inconsistent with the criminal court.
Deaths in custody or care
A death in custody is a death that occurs in one of the circumstances set out in section 3C of the Coroners Act 1997.
Deaths in custody include the death of a person at a correctional centre, lockup or at detention place. It also includes when someone dies while being taken into custody, or while subject to certain other orders.
A death in care is a death that occurs in one of the circumstances set out in section 3BB of the Coroners Act 1997. This includes when a person is under a mental health order, or is being detained under an emergency detention order in accordance with the Crimes Act 1900. This does not include the death of a person in an aged or disability care facility.
A coroner must hold a hearing as part of the inquest into a death in custody or care.
In an inquest into a death in custody or care, the coroner must determine whether the quality of care, treatment and supervision contributed to the cause of death.
Any death that occurs at an ACT correctional facility will also be investigated by the ACT Inspector of Custodial Services. That investigation is independent of the coronial inquest.
Complying with a Subpoena
A coroner may subpoena a person to give evidence or produce a thing or document at a time and date specified in the subpoena.
If you have received a subpoena to produce documents or things to the coroner and are not required to give evidence you may comply with the subpoena by handing over the documents or things to the coroner before the date specified on the subpoena. These can be delivered to the court registry, or in most cases sent electronically to the coroners court registry. If you receive a subpoena to produce documents a letter will accompany the subpoena to explain how you might comply with the order.
If you are served with a subpoena to give evidence you will need to attend the hearing at the time and place specified in the subpoena. If you are unable to attend the hearing as required you should contact the court registry as soon as possible after receiving the subpoena.
At the time of being served with the subpoena you will be given an undertaking to appear, which you must sign and return to the coroner. You will also be given an expenses form to complete to claim your expenses for attending the hearing.
If you fail to comply with a subpoena served on you, the coroner may issue a warrant for your arrest. If you are arrested for failing to comply with a subpoena you will be taken before the coroner, who may direct that you be held in custody or be released on a recognisance to return to court at a specified time. Failure to appear at the later time may lead to you being arrested again and your recognisance being forfeited.