Coroner's cases

A coroner is a person who inquires into deaths that are sudden or unexpected, or where the cause of death is unknown. Coronial services in NSW are coordinated by the State Coroner, located in Glebe. All magistrates of the Local Court are coroners. Registrars at Local Courts in most towns throughout NSW are also coroners or assistant coroners.

Deaths that must be reported to the coroner

A medical practitioner must not issue a certificate as to cause of death if the death is a ‘reportable death’ under the Coroners Act 2009. A ‘reportable death’ is defined in section 6 of the Coroners Act 2009 as where a person has died:

  • a violent or unnatural death
  • a sudden death the cause of which is unknown
  • under suspicious or unusual circumstances
  • 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
  • in circumstances where the person’s death was not the reasonably expected outcome of a health related procedure carried out in relation to the person
  • while in (or temporarily absent from) a mental health facility while the person was a resident at the facility for the purpose of receiving care, treatment or assistance.

Or, under section 23 of the Coroners Act 2009, if the death is a death in custody, where a person has died:

  • while in the custody of a police officer or in other lawful custody
  • while escaping, or attempting to escape, from the custody of a police officer or other lawful custody
  • as a result of, or in the course of, police operations while in, or temporarily absent from a detention centre; a correctional centre or a lock-up
  • while proceeding to a detention centre, a correctional centre or a lockup for the purpose of being admitted and while in the company of a police officer or other official charged with the person’s care or custody.

Or, under section 24 of the Coroners Act 2009, if the death is a death of a child

who was:

  • a child in care, or
  • a child in respect of whom a report was made under the Children and Young Persons (Care and Protection) Act 1998 within the period of 3 years immediately preceding the child’s death, or
  • a child who is a sibling of a child in respect of whom a report was made under the Children and Young Persons (Care and Protection) Act 1998 within the period of 3 years immediately preceding the child’s death,


  • a child whose death is or may be due to abuse or neglect or that occurs in suspicious circumstances.

Or the death of a disabled person who was:

  • living in, or temporarily absent from, residential care (under the Disability Services Act 1993) or a residential centre for disabled people
  • a person who received assistance from a service provider under the Disability Services Act 1993 in order to live independently in the community.

In any of these circumstances the medical practitioner must immediately notify the police so that the coronial procedure can begin. Every death reported to the coroner must be investigated to determine the cause of death.

The deceased must be formally identified by someone who knew them, and the police must complete a report of death to the coroner.

Post-mortem examination

The coroner will require a post-mortem examination to determine the cause of death in those cases mentioned above. A post-mortem examination or autopsy usually involves an internal and external examination of the body by a doctor who has special training and experience in this field, and who has written authorisation from the coroner to perform the post-mortem. The post-mortem is carried out in a forensic mortuary or a hospital authorised to perform a forensic post-mortem, and a report is sent to the coroner.

Objecting to a post-mortem

Next of kin can object to a post-mortem by writing to the coroner explaining their reasons for the objection. The coroner decides whether a post-mortem is necessary or is in the public interest. The coroner must give immediate notice of that decision to the next of kin.

Unless the coroner believes the post-mortem examination must be performed immediately, it must be delayed for 48 hours to allow the next of kin time to apply to the Supreme Court for an order to stay the examination. If it is satisfied that it is desirable in the circumstances, the Supreme Court may make an order that no examination, or only a partial examination, be performed.

Availability of reports

Post-mortem reports and other medical reports are available free to relatives of the deceased person and any person who the coroner believes has ‘a sufficient interest in the circumstances of the death’.

After the post-mortem

When the post-mortem examination is completed, the coroner will allow the body to be taken by the funeral director chosen by the family. Usually, consent for the funeral is given straight after the post-mortem, even if the results are not available. If the next of kin choose a cremation, they have to complete an application for permission for cremation (Form CL36(1)) and get the coroner’s approval (Form C40(1)).

Documents and information

The coroner also issues the coroner’s form of information of death, which is sent to the Registry of Births, Deaths and Marriages. From this form, the registrar completes the cause of death on the death certificate and can then issue the death certificate to the executor or next of kin. The certificate may be issued without a cause of death if the coroner’s form has not been received prior to the certificate being requested.

A pamphlet, NSW Coroner’s Court: a guide to services, is available from the Coroner’s Court to assist people through the coronial system. It can be accessed from the Coroner's Court website.

Coronial information and support

The Coronial Information and Support Program (CISP) is designed to provide information and support for those families affected by sudden death in New South Wales, including face to face and telephone support for people during the coronial process. The CISP is not a counselling unit.

Counselling units are available through the Department of Forensic Medicine in Glebe and Newcastle and provide access to forensic counsellors (social workers). They can provide information, support and bereavement/ trauma counselling for families and friends involved in the coronial process.

Coroner’s inquests

Once the initial investigation is complete, the coroner decides whether or not an inquest will be held. An inquest is a public hearing before a coroner to find out the date, place, cause and manner of death, and the identity of the deceased. If the investigation reveals evidence of an indictable offence by a known person, and the coroner believes the evidence would satisfy a jury beyond reasonable doubt, the coroner must refer the case to the Director of Public Prosecutions.

In most cases, the results of the post-mortem and preliminary police investigations will establish that death was by natural causes and an inquest will not be necessary. Under the Coroners Act an inquest can be dispensed with in a broad range of cases.

An inquest is held in approximately 10 per cent of cases reported to a coroner. All murders involve an inquest, except where someone has already been charged in connection with the death.

If an inquest is not held

If an inquest is not going to be held, the coroner will notify the next of kin of this decision in writing. Any person who is considered to have ‘sufficient interest in the circumstances of the death’ may ask the coroner why an inquest was not held. If you are unhappy about the coroner’s decision not to hold an inquest, you may write to the coroner to ask for an inquest and give your reasons for wanting it.

Relatives should find out all they can about coronial inquiries and the associated advantages and disadvantages before making a decision to request one. Information is available from the counsellors at the Coroner's Court.

If an inquest is to be held

If an inquest is to be held, the coroner will send the details of the time, date and place of the hearing to the next of kin. If you are not the next of kin, you should write to the coroner as soon as possible and ask for the details of the inquest.

The Coroner’s Court

Inquests are held in the Coroner’s Court. The coroner normally hears all the evidence alone, although they can have a jury of six to assist them. They are not bound by the normal rules of evidence and procedure.

At the inquest, interested parties, including relatives, have a right to appear and to be legally represented. You must give the coroner notice in writing of your intention to appear. It is then the coroner’s responsibility to inform the parties of the time and place of the inquest.

All witnesses called to give evidence must do so. They may be questioned further about their evidence by an interested party or a solicitor acting for that party.

An inquest hearing in court may take less than a day or up to a few weeks to complete. At the end of an inquest, the coroner will make a finding as to the circumstances of the death and may make recommendations to the relevant authorities. If the coroner decides that there is a case against any person for any serious offence, a record of the inquest is forwarded to the Director of Public Prosecutions. The Director of Public Prosecutions may decide to proceed against the person concerned, in which case they will be charged and tried in court in the usual manner.

If you are not satisfied with the outcome of the inquest, it may be possible to have another one held. You should seek legal advice before proceeding with this course of action.