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Coronial Inquests (WA)

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 Western Australia, such inquests are conducted by a coroner under the Coroner’s Act 1996. 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 Western Australian 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 during an anaesthetic;
  • occurs as the result of an anaesthetic and is not due to natural causes;
  • is of a person in care, custody or psychiatric detention;
  • appears to have been caused or contributed to while the person was in care;
  • appears to have been caused or contributed to by any action of police;
  • is of a person whose identity is unknown;
  • is one where a cause of death certificate has not been issued;
  • is one that occurs in a place outside Western Australia and a cause of death certificate has not been issued under the law of that place.

A “Western Australian death” means:

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

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 death was in custody or in care;
  • the death appears to have been caused or contributed to while the person was in custody or care;
  • it appears to have been caused or contributed to by any action of police;
  • an inquest is directed by the Attorney-General or State Coroner.

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.

A State Coroner can order an inquest where a person is missing and the State Coroner reasonably suspects the person has died and the death was a reportable death.

The coronial inquest 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.


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. Where a person dies in care, the coroner must comment on the quality of the supervision, treatment and care of the person while in that care.

A coroner can report information to the Director of Public Prosecutions if the coroner believes a serious offence has been committed in connection with the death, or to police if the coroner believes a lesser offence has been committed.

However, the coroner must not frame a finding or comment in a way that suggests a person is guilty of an offence or has civil liability for an action.

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

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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