The Coroners’ Court: the coronial process explained

The death of a loved one in any circumstances can be extremely traumatic for family and friends. But when there are unanswered questions about what or why a death happened, it can make that grief even harder to bear.

When someone dies following medical treatment, relatives will want answers about what happened, whether it was preventable and, if so, what can be done to prevent it happening to anyone else. 

Through coronial investigation, a coroner plays an important part in getting some of these answers and establishing the circumstances surrounding an unusual or unexplained death.

What are the duties of a coroner in the coronial process?

Certain unexplained or unusual deaths are reported to a coroner to carry out an independent coronial investigation.

The coroner is responsible for investigating, establishing and recording the facts; who the deceased is, what happened, where, when and why. They are also responsible for investigating the circumstances surrounding a death and making recommendations designed to prevent other deaths in the future.

The coronial investigation may look into:

• unexpected, unnatural or violent deaths (including homicides and suicides)
• when the identity is not known
• when the cause of death is not known
• when a person dies who was in care, custody or as the result of police activity.
• when the death was caused by preventable or unusual factors, including the acts or omissions of third parties.

The coroner does not attribute blame, it is a fact-finding process.

Do Coroners investigate medical negligence?

Deaths during or following medical treatment tend to be reported to a coroner for investigation when certain red flags are raised. Generally speaking, a death arising from medical treatment is reportable when:

1. the death may have been caused by the medical treatment or procedure; or
2. the death was unexpected.

What powers does a Coroner have during the coronial process?

Coroners have considerable powers, including summoning witnesses and medical experts to give evidence at a coronial inquest.

They can also authorise police officers or other persons to take statements from witnesses, gather evidence, take possession of a body, or conduct an autopsy.

In the context of negligent medical treatment claims, a coroner also often asks people working within the Court to undertake investigations, research, obtain expert evidence and form a preliminary opinion about the circumstances surrounding the death and the role the treatment played in it.

What is an autopsy?

An autopsy is a detailed external and internal medical examination of the deceased’s body conducted by a forensic pathologist and is used to determine the medical cause of death. However, it may not look at the wider circumstances surrounding the death, including whether medical treatment may have caused it.

Many deaths that are reported to the coroner may result in an autopsy being undertaken. However, this does not necessarily mean that the coroner will undertake a wider investigation or order an inquest.

The deceased’s next of kin can object to an autopsy taking place, particularly if there are religious or cultural reasons. Any such objection needs to be made in writing to the Court.

What is a coronial inquest?

A coronial inquest is a public hearing intended to help establish the facts around a death. Not all deaths reported to the coroner will end in an inquest. Often, a coroner will be able to conduct their investigation based on the available information without the need to holding a coronial inquest.

However, there are circumstances where a public hearing will be held, in which experts and witness will be asked to give evidence and be asked questions by the coroner, representatives of the deceased and other interested parties.

Relatives of the deceased can attend and ask questions, but this can be distressing due to the graphic information which may be examined as part of the process. In many cases, they will be represented by a lawyer, who can ask questions on their behalf.

Can I request a coronial investigation or coronial inquest?

You can request a coronial investigation into a death by writing to a coroner. Not all requests are actioned and a coroner will only investigate a death if it satisfies a particular criteria.

It is important to understand your rights and options before requesting a coronial inquest.

Getting answers and understanding what led to a loved one’s death can be an important part of the grieving process.

It can be a painful process for friend and family, but the coroners’ court has a vital role in shedding light on tragedy and helping prevent similar tragedies taking place in the future.

How can Maurice Blackburn help with a coronial inquest?

We understand that a coronial investigation or inquest can be a daunting and emotional process for those involved. Get in touch with our experienced medical negligence lawyers who can provide support and guidance throughout the process.