What are Coronial Inquests?

What are Coronial Inquests?

Coronial inquests (or inquests as they are often called) are public hearings held in the Magistrates Court, to determine the cause of a person’s death and how the person died if it is unknown.

The purpose of an inquest is to find out what happened in the lead up to the person’s death and the likely cause of death. An inquest is not held to determine who was necessarily responsible for the person’s death although they often lead to persons of interest being named by the Coroner and recommendations being made on whether anyone should be criminally charged for the cause of death.

Inquests are solely concerned with what the factual circumstances surrounding the cause of a person’s death.

Inquests are held in the Magistrates Court in Queensland. The presiding Magistrate sits as the Coroner for the proceeding.

When is a Coronial Inquest held?

A Coronial Inquest will be held when the cause of death is not known or there are questions surrounding how the person died and why. Not all deaths require a Coronial Inquest.

There are a number of circumstances when an Inquest will happen as a matter of course, these are when the identity of the deceased person is not known, a person has died in a health-care environment, the death was unnatural or violent or suspicious, a death certificate has not been issued and cannot be issued as the location of the body is not known or if the Coroner orders for an Inquest to take place.

If a person dies in custody, or as the result of a police operation, then an Inquest must take place. This is so, even the cause of death is obvious and known.  This is also the case if a person dies in care and there are some questions surrounding the appropriateness of the care being received by the person. Care could be of a child, a disabled person or someone in a mental health care facility.

The family of a person may also request that an Inquest be held. However, coronial inquests do not always take place even if they have been requested by the family or the relevant agency. The Coroner’s office will consider submissions from police and members of the public and then determine which matters require further investigation and an inquest.

The Coroner’s office will consider all requests made for an inquest and then determine whether one should take place or not. The Coroner’s office will provide the person requesting the inquest with their written decision as to why they have agreed to hold an inquest or not. The Coroner must be satisfied that it is in the public’s best interest to hold an inquest to decide to do so.

If a person is not happy with the Coroner’s decision, they may seek a review of it by applying to either the Coroners Court or the District Court within 14 days of the original decision.



What happens at a Coronial Inquest?

The first step in the Inquest process is for the Coroner to schedule a Pre-Inquest Conference.

The Pre-Inquest Conference is preliminary Court date for all those interested in the death (interested parties), to attend at the Coroners Court for the Coroner to issue directions for the future progression of the matter.

Directions are usually such things as who will be allowed to appear and be heard at the inquest, the location of the Court where it will be held, and which witnesses will be questioned and as such who are required to provide written statements on their knowledge of the death.

Anyone who has a direct interest in the outcome of the inquest are likely be given leave to appear at the Inquest. Those who are allowed to appear can do so on their own or with lawyers acting for them. The Coroner even has Counsel who assists them through the process.

An overview will be provided on the particular issues the Coroner believes need to be considered. The other parties can make submissions on any other issues they believe should be considered during the process as well.

The police and Coroner’s office will obtain witness statements from people who are able to provide information on the circumstances of the death. Witnesses may include the last people to see the deceased, the medical team who worked on the deceased, police officers who investigated the death and anyone else involved in the lead up to the death. During the Inquest the witnesses will be questioned under oath. The witnesses will be questioned on their statements.

Coronial Inquests commence some weeks or months after the Pre-Inquest Conference. This time frame allows the parties to prepare for the Inquest and to receive the paperwork from the police and the counsel assisting the Coroner including the witness statements.

What is the Coroner required to determine?

The Coroner is required to establish who the deceased was, where and when they died and what the cause of death was. Part of the Coroner’s job is to make recommendations on what changes should be made in an effort to prevent similar deaths occurring in the future.

What happens if the Coroner believes criminal activity caused the death?

The Coroner also determines whether there is a reasonable suspicion that someone committed a criminal offence. If the Coroner decided that criminal activity played a part in the cause of death, they will refer the matter to the Director of Public Prosecutions to make further enquiries and decide whether they should prosecute the person of interest.

Can the Coroner make a non-publication order?

An application can be made to the Coroner asking them to make a non-publication order. If the Coroner is satisfied that it is necessary and in the interests of justice, they can make a non-publication order which means that the names of witnesses appearing at a coronial inquest cannot be published. This is common in high profile cases, where witnesses may be less likely to give open and honest evidence if their identity is likely to be published in the media. It is also likely where the publishing of the identity of a potential suspect in a future criminal investigation could lessen the likelihood of them receiving a fair trial.

What outcomes can you expect following an inquest?

The outcomes from a Coronial Inquest are many and varied. The Coroner is also able to make recommendations on all aspects of matters depending on the topic and scope of the particular Inquest.

Inquests often highlight deficiencies in medical systems or specific hospitals. This happens when someone has died from a failure in their medical care.

Inquests often highlight problems or deficiencies in systems such as the prisons, hospital, watch houses etc. Coronial Inquests often highlight these deficiencies and make recommendations for them to be remedied. The Coroner is able to state specifically what remedies they would recommend. The recommendations from Inquests can fix safety issues on job sites or in certain industries making workplaces a safer place to be.

An inquest may find that a contributing factor in a death was lack of public knowledge of the dangers of a particular act such as under immunising children due to the different strains of a particular illness. When this happens, the Coroner is likely to recommend A recommendation for a public awareness campaign may therefore be made. The Coroner may also make recommendations for legislation to be reviewed or amended in light of the death.

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