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Coronial Inquests (ACT)

A coronial inquest is an inquiry to determine the identity of a dead person, how they died, and the place, date and cause of their death. In the Australian Capital Territory, such inquests are conducted by a coroner (magistrate) under the Coroner’s Act 1997. The Act mandates that an inquest must be held to investigate a death that occurs in specific circumstances, and a hearing may form part of the inquest.

When a coronial inquest is held

Under the Act, a coroner must hold an inquest into the death of a person who dies:

  • violently, or unnaturally or in unknown circumstances;
  • in suspicious circumstances;
  • in care or custody;
  • and the death appears to be completely or partly attributable to an operation or procedure;
  • after having undergone an operation or procedure and the Chief Coroner believes the circumstances should be better ascertained;
  • and a doctor has not given a certificate about the cause of death;
  • and has not been attended by a doctor anytime in the 6 months prior;
  • after an accident where the cause of death appears to be directly attributable to the accident;
  • or is suspected to have died in circumstances that the Attorney-General believes should be better ascertained.

An inquest can be held even when the body is outside the ACT, has been destroyed, is in a place from where it cannot be recovered, or cannot be found. It can also be held if a person dies outside the ACT but the person normally lived in the ACT.

A coroner can also hold an inquest if they are satisfied it is in the public interest to do so. This could be because there is doubt about the circumstances of the death, or the death has brought to light serious concerns that affect public health and safety.

The coronial inquest process

The coroner investigates the circumstances of the death in several steps. After a death is reported, the corner may order an autopsy on the body, and the family of the dead person is notified the death is being investigated. Once the autopsy is complete and no further tests need to be done, and after the body is formally identified, the body is released for burial or cremation. Police then help the coroner investigate the death, via obtaining medical records or witness statements or other functions. The coroner can seek additional reports, statements or information about the death, including from health professionals, engineers, workplace health and safety inspectors or air safety officers. At the end of the inquest, the coroner issues written findings.


If a death occurs in care or custody, a hearing must be held as part of an inquest. Otherwise a coroner has discretion as to whether to hold a hearing. The hearing is usually open to the public but a coroner can exclude certain people from the hearing and/or prohibit publication of evidence heard. Once all the evidence has been presented, the coroner usually adjourns the hearing to consider the evidence and submissions and make their findings. The findings can be delivered on the same day but are usually delivered at a later date.

Coronial inquest findings

The findings usually contain recommendations on matters related to public health or safety, or the administration of justice, to help prevent deaths from similar causes.

If a coroner provides a report to the Attorney-General, and the report contains comments or recommendations about a matter of public safety, or findings about a risk to public safety, the Attorney-General must present the report to the Legislative Assembly within 6 months. On that day the report is presented, a response to the report must be provided.

If a coroner reasonably believes a person mentioned at the inquest has committed a serious offence, the coroner must inform the Director of Public Prosecutions (DPP). The coroner must consider the admissibility at trial of any evidence given at the inquest, and whether the DPP, or a person who may be affected by the referral, has been given the opportunity to give evidence. If the coroner informs the DPP, the coroner must stop the inquest until the DPP determines the matter. The coroner can continue an inquest after a court judgment has been delivered but they must not make a finding inconsistent with that judgment.

Most findings from coronial inquests that involve a hearing are published on the ACT Courts website. Those that do not involve a hearing are not generally not published unless the coroner directs they be published, for example when recommendations are made or when the inquest is of public interest.

For advice or representation in any legal matter, please contact Armstrong Legal.

Sally Crosswell

This article was written by Sally Crosswell

Sally Crosswell has a Bachelor of Laws (Hons), a Bachelor of Communication and a Master of International and Community Development. She also completed a Graduate Diploma of Legal Practice at the College of Law. A former journalist, Sally has a keen interest in human rights law.

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