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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.

Coronial Inquests (Vic)


A coronial inquest is a public inquiry to determine the identity of a dead person, how they died, and the place, date and cause of their death. In Victoria, such inquests are conducted by a coroner under the Coroner’s Act 2008. An inquest must be held for certain deaths but can also be ordered by a coroner in certain circumstances if there are broader issues of public health and safety that should be examined.

Reportable deaths

Under the Act, a coroner must investigate a “reportable death”. A death is a reportable death if:

  • the death happens in Victoria;
  • the body is in Victoria;
  • the cause of death occurred in Victoria;
  • the person ordinarily lived in Victoria.

If the above criteria are satisfied, further criteria then apply. The death is a reportable death if it:

  • appears to have been unexpected, unnatural or violent, or to have resulted, directly or indirectly, from an accident or injury;
  • occurs unexpectedly during a medical procedure or following it where the procedure may be the cause;
  • is of a person in custody or care;
  • is of a person in psychiatric detention;
  • is of a person in police custody;
  • is of a child under a supervision order;
  • is of a person whose identity is unknown;
  • is one where a cause of death certificate has not been issued, and is not likely to be issued, for the person;
  • is one that occurs in a place outside Victoria and a cause of death certificate has not been issued, and is not likely to be issued, for the person under the law of that place.

The Act states the coroner must investigate a reportable death if it occurs within 50 years of it being reported. The coroner may investigate if the death occurs within 100 years of it being reported.

Reviewable deaths

A reviewable death is the death of a second or subsequent child of a particular parent or parents. The definition of parent includes a step-parent, foster parent, adoptive parent, guardian or other person who has custody or daily care and control of the child. Reviewable deaths do not include those of stillborn children or children who die in hospital having never left the hospital after birth.

When a reviewable death is reported, a coroner decided whether the death should be investigated. Reviewable death is investigated to:

  • determine the child’s identity, and cause of death;
  • assess the family’s health needs;
  • assess the needs of any other siblings or any risk to other children.

The investigation 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 investigation, the coroner issues written findings and decides whether an inquest should be held.

When a coronial inquest is held

Only a small number of coronial investigations proceed to an inquest. An inquest must be held if the:

  • coroner suspects the death was the result of homicide;
  • death was in custody or in care;
  • the identity of the person is unknown.

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.

An inquest does not have to be held when:

  • someone has been charged with a serious offence in connection with the death;
  • an interstate coroner has investigated, is investigating , or intends to investigate the death;
  • the death occurs outside Australia;
  • the coroner considers the death was due to natural causes.

The process

The coroner determines the issues to consider, the parties involved, the witnesses to be called, and when and where the inquest is to be held. An inquest 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.

A coroner can report their findings in relation to a death to the Attorney-General, and can make recommendations to any government minister or public statutory authority on any matter connected to the death.

When a public statutory authority receives a recommendation from the coroner, it must respond, in writing, within 3 months, stating what action, if any, has or will be taken.

Findings from coronial inquests are published on the Coroners Court of Victoria website.

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

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