Coronial Inquests in NSW – Frequently Asked Questions

Nov 23, 2022 | Publication | 0 comments

When someone dies unexpectantly, the media often say that “a report will be prepared for the Coroner”. But what does the Coroner do?  And what are the powers of the Coroner?

What does the Coroner do?

The Coroner investigates certain kinds of deaths, suspected deaths, fires and explosions.

The Coroner can, for instance, determine the identity of the deceased, the date, place, circumstances and medical cause of death.

The role of the Coroner is to determine what happened, not to pursue any person who may be responsible.

When will the Coroner investigate a death?

Generally speaking, if the death occurs where a person has died:

  1. A violent or unnatural death;
  2. A sudden death the cause of which is unknown;
  3. Under suspicious or unusual circumstances;
  4. In circumstances where the person had not been attended by a medical practitioner during the period of six months immediately before the person’s death;
  5. In circumstances where the person’s death was not the expected outcome of a health related procedure carried out in relation to the person; or
  6. While in or temporarily absent from a declared mental health facility and while the person was a patient of the facility,

the Coroner will examine the person’s death.

What outcomes arise from Coronial Inquests?

After an inquest, the Coroner may make recommendations to governments and other agencies.

The Coroner cannot enforce compliance with recommendations.

Who is responsible for deciding whether a Coroner’s recommendations should be adopted?

The government is ultimately responsible for determining whether a Coroner’s recommendations should be adopted.

Since 2009, the government’s responses to coronial recommendations have been published by the NSW Department of Attorney General and Justice.

Can a Coroner determine civil liability?

No. Having said that, the Coroner’s findings may impact subsequent civil proceedings and/or insurance claims.

If a person dies “in custody”, is it mandatory to have a Coronial Inquest?


Can the Coroner summon witnesses?


Can the decision of a Coroner be appealed?


Can a Coroner investigate even if there is no body?

At common law, a Coroner has no power to conduct an enquiry where no body was found. Modern statutes such as the Coroners Act 2009 (NSW) grant the Coroner jurisdiction to enquire into suspected deaths.

Can a senior next of kin ask for a post-mortem examination not to be performed?

Yes. Generally speaking, the senior next of kin may ask for a post-mortem examination not to be performed on the deceased, however if the Coroner decides it is necessary to conduct a post-mortem, he or she must give written notice immediately to the senior next of kin of such a decision. There are appeal rights.

Who has the right to possession of the body?

The Coroner has the right to possession of the body of anyone killed violently and has authority over the physical control of the body. This authority lasts until the conclusion of the inquest.

Can the Coroner dispense with an inquest?

Yes, the Coroner can dispense with an inquest. Such dispensation of an inquest may occur where the Coroner is satisfied that the deceased person died of natural causes (whether or not the precise cause of death is known) and a senior next of kin of the deceased person has indicated to the Coroner that it is not the wish of the deceased person’s family that a post-mortem examination be conducted on the deceased to determine the precise cause of the deceased person’s death.

We strongly recommend that you obtain legal advice regarding your particular circumstances.

The information in this publication is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavour to provide accurate and timely information, we do not guarantee that the information in this publication is accurate at the date it is received or that it will continue to be accurate in the future. We are not responsible for the information of any source to which a link is provided or reference is made and exclude all liability in connection with use of these sources.

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