Deaths are usually reported to the coroner by the police who attend the scene of a death (or by a medical practitioner i.e. in a hospital) or to the coronial registrar by a medical professional.
Once a death is reported, they investigate the circumstances of the death to establish:
- the identity of the deceased
- when they died
- where they died
- how they died
- the medical cause of death
The coroner controls and coordinates each step of the investigation. Police officers generally help the coroner gather evidence.
Many of the below steps happen within a few days. However, a coronial investigation may take several months to be finalised. As every case is different the time to finalise can vary. The length of time depends on the case’s unique circumstances.
These are the basic steps of a coronial investigation:
- The death is reported to the coroner, usually by police who attend the scene and get initial information about the death from family members, friends and witnesses. The coroner and/or registrar is notified of the death by a police report (Form 1) or medical professional (Form 1A).
- The deceased is transported to a mortuary – if preliminary examination or an autopsy is required, police arrange for the government-contracted undertaker to take the deceased to a mortuary.
- The coroner orders an autopsy (if necessary) to help determine how and why the person died. Family and cultural concerns are considered before ordering an internal autopsy.
- Family may be contacted by Coronial Family Services – counsellors or coronial nurses may contact you about the death and autopsy process.
- Family will be notified by the Coroners Court - the nominated family member will be advised in writing that the death is being investigated. Family will be updated throughout the investigation by a case manager.
- The deceased is released for burial or cremation – if a medical examination of the deceased is undertaken, and the deceased person is formally identified, the deceased may be released to the family.
- Police help the coroner investigate the death – after reviewing the initial report of death the coroner/registrar may ask police to investigate further, possibly including getting medical records and further statements from witnesses. The coroner has wide powers of investigation, and can request additional reports, statements or information about the death. They may obtain more information from police, doctors, engineers, workplace health and safety inspectors, mining inspectors, air safety officers, electrical inspectors and other witnesses.
- Coroner completes their enquiries - once the coroner has completed their investigation, they consider whether to hold an inquest (public hearing) into the death. The coroner consults with the family, who can also make a request for the coroner to hold an inquest. Most coronial investigations are finalised without an inquest.
- Coroner makes written findings - at the end of the investigation, the coroner makes written findings and sends a copy to the family.