Judicial decisions

A non-exhaustive list of decisions relevant to the coronial jurisdiction.

Atkinson v Morrow [2005] QCA 353; [2006]1 Qd R 397 (05/4253) Brisb McPherson JA Cullinane J Jones J 23/09/2005

Magistrates - Coroners - the Coroner and the Coroner's Court - Proceedings at inquest or inquiry – inquest into the death of person who died shortly after being left by police in a remote area – whether coroner exceeded his jurisdiction – whether evidence of senior police officer should have been admitted – whether senior police officer required to give evidence at inquest.

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Attorney-General for the State of Queensland v Barnes & Anor [2014] QCA 152

Appeal and new trial – practice and procedure – Queensland – Time for appeal – Extension of time – General principles as to grant or refusal – where the first respondent conducted an inquest into the deaths of two women – where the second respondent was committed to stand trial on a charge of unlawful killing – where the decision to commit the second respondent to stand trial was set aside on judicial review – where the applicant/appellant intervened in the judicial review proceeding – where the applicant/appellant seeks an extension of time to appeal against the substantive decision on the ground that the trial judge erred in his analysis of the first respondent’s findings regarding the admissibility of lies – where there was some explanation for the delay – where there was no real prejudice to the respondent – where there were no real prospects of success on appeal – whether an extension of time should be granted.

Appeal and new trial – practice and procedure – Queensland – powers of the court – costs – where the applicant/appellant intervened in the judicial review proceeding overturning the first respondent’s decision to commit the second respondent to stand trial – where costs were awarded against the applicant/appellant – whether the trial judge erred in applying irrelevant criteria in exercising his discretion as to costs – whether the trial judge erred in awarding costs against the applicant/appellant rather than the State – whether the appeal against costs should be allowed.

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Christensen & Anor v Deputy State Coroner [2021] QSC 38; Brisbane, Rafter AJ, 04/03/2021

ADMINISTRATIVE LAW - JUDICIAL REVIEW - REVIEWABLE DECISION AND CONDUCT - REVIEW OF PARTICULAR DECISIONS - where the applicant seeks judicial review of a Coroner's directions that  a witness be excused from giving oral evidence - where the witness is suffering from post-traumatic stress disorder and giving oral evidence would adversely impact the witness' mental state - where the witness is instead directed to provide sworn answers in writing - whether the Coroner's directions are liable to be quashed or set aside because the Coroner did not have the power to make the directions.

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Davis v Ryan [2018] QDC; Townsville, Lynham DCJ, 10/09/2018

Coroners Act, application to hold inquest where state coroner has refused the application, whether inquest would be “in the public interest”

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Davis v Ryan, State Coroner [2019] QCA 282; Brisbane, Lynham DCJ, 03/12/2019

APPEAL AND NEW TRIAL – PROCEDURE – QUEENSLAND – TIME FOR APPEAL – EXTENSION OF TIME – WHEN GRANTED – where the application for leave to appeal was filed out of time – where the decision the subject of the application was forwarded to the applicant at the wrong email address – where the applicant acted promptly to file his application once he received the judgment – whether an extension of time should be granted for the application for leave to appeal.

ADMINISTRATIVE LAW – JUDICIAL REVIEW – REVIEWABLE DECISIONS AND CONDUCT – DISCRETION NOT TO ENTERTAIN APPLICATION – GENERALLY – where the applicant applied to the District Court for an order to hold an inquest into the death of his late wife – where the District Court judge was not satisfied under s 30(8) of the Coroners Act 2003 that holding an inquest would be in the public interest, and dismissed the application – where the applicant sought leave to appeal from the District Court judge’s decision – whether leave is necessary in order to correct a substantial injustice – whether there is a reasonable argument that the District Court judge committed House v The King error in forming the discretionary judgment that he was not satisfied that holding an inquest was in the public interest – whether the District Court judge misconstrued the term “public interest” in s 30(8) – whether the District Court judge took into account irrelevant considerations by having regard to the State Coroner’s views as to the utility of an inquest and the availability of resources, and to opinion evidence from doctors – whether the District Court judge failed to have regard to a relevant consideration as to an alleged widespread dangerous prescribing practice or simply did not make the finding of fact the applicant sought.

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Gentner v Barnes [2009] QDC 307; Maroochydore, J.M. Robertson, 30/09/2009

Coroners Act, application to hold inquest where State Coroner has refused the application, whether inquest would be “in the public interest’, nature of test to be applied, consideration of State Coroners Guidelines in relation to inconsistency and/or uncertainty in evidence relating to the cause of fatal accident, consideration of views of family of deceased person in relation to the issue of public confidence in the administration of justice, delay and consideration of earlier decision by local Coroner to hold inquest.

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Kontvainis-Hay v Hutton [2012]; Brisbane, J. Douglas, 12/11/2012

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Liston v Pierpoint [2009]; Brisbane, Douglas J, 15/07/2009

Transcript of proceedings

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Morant v Terry Ryan (The State Coroner) [2022] QDC 134; Brisbane, Loury QC DCJ, 10/06/2022

CORONER – INQUESTS AND INQUIRIES – where an application to hold an inquest in circumstances where the State Coroner has refused to do so – whether inquest would be in the public interest

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Parsons v Ryan (State Coroner) [2022] QDC 237; Brisbane Prskalo A/DCJ 04/11/2022

MAGISTRATES – CORONERS – INQUESTS AND INQUIRIES – where there is an application for an order by the District Court under s 11A Coroners Act 2003 that a death is a ‘reportable death’ on the basis that it meets the statutory definition of a ‘health care related death’ under s 10AA – where the application is refused on the basis that the objective requirements of s 10AA were not satisfied by the evidence.

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Bilbao v Farquhar and Others [1978]; Sydney, Moffit P., and Hutley and Glass JJ.A, 16/08/1978

Inquest into death of person while in custody—Inquest commenced—Charge of murder against police officers—Inquest adjourned—Police discharged at conclusion of committal proceedings—Decision by coroner not to resume inquest—Court has power to quash inquest, though not completed, and to order another inquest—Meaning of “inquest … has been held”—Coroners Act, 1960, ss. 28 (3), 37 (2).

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Douglas Edward Farrar v Coroners Court of Victoria [2022]; VSCA 246, Melbourne, Macaulay JA, Lyons and J Forrest AJJA, 11/11/2022

Coroner – Determination by Coroner that death not a ‘reportable death’ – Appeal to single judge on question of law, pursuant to Part 7 of the Coroners Act 2008, dismissed – Nature of appeal to the Court of Appeal in light of Part 7 of the Coroners Act 2008 – No error of the judge in concluding that the Coroner’s determination that death was not a ‘reportable death’ (on basis that the determination was not against the evidence and the weight of evidence) – Nature of ‘preliminary examination’, Coroners Act 2008 s 3(1) – No error of the judge in concluding that ‘preliminary examination’ did not require an examination of the body of the deceased – No requirement under the Coroners Act 2008 that a coroner ‘direct’ a ‘preliminary examination’.

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Harmsworth v The State Coroner [1989]; VR 989; Victoria, Nathan J, 09/03/1989

Powers of investigation, comment and recommendation – Extent of powers – Matters “connected with” death – Coroner’s Act 1985 (No 10257), s17(1), s19(2), s21(2)

Administrative law – Remedies – Declaration – Prohibition – Whether State Coroner amenable.

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R v Bain (No 2) Criminal Trial by Judge Alone [2018]; SADC 88; South Australia, Chapman DCJ, 20/08/2018

Accused charged with two counts of supplying a controlled drug - interviewed by police as part of a coronial investigation into the death of his partner but also as a suspect for supplying her with methylamphetamine - application to exclude interview on basis it would be unfair to admit it at his trial. Held: Interview excluded in exercise of discretion - at the time of the caution the police failed to make accused aware of the nature of the crime about which he was to be questioned - further, when police did advise accused of the nature of the crime, he was not cautioned.

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W K Abbott v Coroners Court of New Plymouth and Ors HC NWP CIV-2004-443-660 [2005]; Wellington, Randerson J, 20/04/2005

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Black Action Defence Committee v Huxter, Coroner [1992]; Ontario, Steele, Montgomery and Adams JJ, 21/12/1992

Inquest -- Standing -- Mentally ill member of black community fatally shot by police officer -- Trial of police officer and investigation by O.P.P. revealing no evidence that race was direct factor in shooting -- Coroner correctly denying standing to organization which sought to raise concerns of black community that race played direct role in shooting -- Organization not having substantial and direct interest in inquiry -- Coroner erring in denying standing to organization with expertise on need for cross-cultural training in dealing with mentally ill -- Issue to be raised at inquest by at least one witness -- Issue not peripheral -- Organization having direct and substantial interest in issue -- Coroners Act, R.S.O. 1990, c. C.37, s. 41(1)

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G L Gravatt v The Coroner’s Court at Auckland and Auckland District Health Board [2013]; NZHC 390; Auckland, Whata J, 04/03/2013

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R Maughan v Oxfordshire Senior Coroner (Chief Coroner of England and Wales and another intervening) [2019] 3 WLR; Underhill, Davis, Nicola Davies LJJ, 09/04 – 10/05/19

Inquest - Standard of proof - Death by hanging in prison cell - Whether criminal or civil standard of proof applying to question of whether deceased dying by suicide - Whether standard of proof differing depending on whether conclusion given in short form or narrative form - Human Rights Act r998 (c 42), Sch r, Pt I, art 2r - Coroners and Justice Act 2009 (c 25), s 5(2)2

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People First of Ontario v. Ontario (Niagara Regional Coroner) [1991]; CarswellOnt 705; Ontario, Hartt, Montgomery, Campbell JJ, 09/10/1991

Judges and Courts --- Coroners -- Jurisdiction of Coroner.

Judges and Courts --- Coroners -- Coroner's inquest -- Nature of inquest.

Notwithstanding the emerging public interest in the jury recommendations in the modern Ontario inquest, an inquest is not a Royal Commission. Nor is it a trial, public platform, campaign, lobby or crusade.

Judges and Courts --- Coroners -- Coroner's inquest -- Procedural requirements.

Right of coroner to restrict participation of intervenors.

In a coroner's inquest, if an intervenor's direct and substantial interest extends to the facts surrounding the individual deaths being investigated, then such intervenor should have the same rights as other parties. If their direct and substantial interest is limited to the social and preventive functions involved in the potential jury recom[1]mendations, then their rights of cross-examination and participation should be corre[1]spondingly limited to the extent it can be done fairly. It is open to a coroner to distin[1]guish between degrees of direct interest by the various parties to an inquest, and to limit the participation of each intervenor to the issues of fact vital to their particular interest. The question in each case is whether that can be done fairly.

Judges and Courts --- Coroners -- Coroner's inquest -- Evidence.

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R v Coroner for the Southern District of Greater London; ex parte Driscoll [1993]; Greater London, Kennedy LJ, 22/10/1993

Judicial Review

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R v HM Coroner for Derby and South Derbyshire ex parte Hart [2000]; Derbyshire, Newman J, 07/04/2000

Coroners law -- purpose of inquest -- disallowance of questions -- verdict of unlawful killing.

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R v HM Coroner for Inner South London, ex parte Epsom Health Care NHS Trust [1994]; London, Steyn LJ, 14/07/1994

Coroners law -- lack of care -- adequacy of coroner's direction to jury -- amendment of verdict

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Regina v Her Majesty’s Coroner at Hammersmith [1980]; QB 211; 14/12/1979

Inquest - Jury - Death from blow on head at political demonstration - Suggested unauthorised use of lethal weapon by police - Whether "circumstances... recurrence of which is prejudicial to... health or safety" - Whether coroner bound to summon jury - Coroners (Amendment) Act 1926 (16 & 17 Geo. 5, c. 59), s. 13 (2) (e) - Criminal Law Act 1977 (c. 45), s. 56 (1) (2) Coroner - Inquest - Police statements - Statements taken from witnesses by police - Available to coroner f or his use - Whether disclosable to interested party - Coroners Rules 1953 (S.I. 1953 No. 205), r. 16 (1) n1

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Regina v Poplar Coroner , Ex parte Thomas [1993] QB 610; 15/12/2024

Coroner - Inquest - Duty to hold - Deceased having severe asthma attack - Deceased suffering cardiac arrest while waiting for ambulance - Post mortem showing death by natural causes - Possibility of delay in arrival of ambulance contributing to death - Coroner refusing to hold inquest - Whether reason to suspect that death "unnatural" - Coroners Act 1988 (c. 13), s. 8(1)

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Stanford v Ontario (Eastern Regional Coroner) [1989] CarswellOnt 441; Ontario, Craig, O'Brien and Campbell JJ, 25/07/1989

Judges and Courts --- Coroners -- Coroner's inquest -- Procedural requirements -- View.

Judges and courts -- Coroners -- Coroner's inquest -- Standing -- Inquest into suicide of inmate in unique "super-protective custody unit" in penitentiary -- Remaining in[1]mates of unit unsuccessfully seeking standing at inquest -- Application for judicial re[1]view of coroner's decision -- Inmates having a "direct and substantial" interest in po[1]tential recommendations of inquest -- Coroners Act, R.S.O. 1980, c. 93, s. 41.

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Worcestershire County Council, Worcestershire Safeguarding Children Board v HM Coroner for the County of Worcestershire [2013] EWHC 1711 (QB); London, Jeremy Baker, 02/05/2013

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