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The Coroner is a Judicial Officer who must be advised when a person dies apparently from unnatural causes or where the cause of death is not known.

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The Coroner's responsibility

 Once a report of death is received, usually from the police, doctors or hospital authorities, the Coroner has legal control over the body of the deceased person and must establish:

  • The manner in which the death arose;
  • The cause of death;
  • The particulars needed to register the death; and
  • The identity of the deceased.

In some cases the Coroner may comment and make recommendations about public health or safety or the administration of justice, to help prevent similar deaths happening.

DirectionsThere does not have to be anything suspicious about the death for the Coroner to be involved. Many investigations involve people who have died of natural causes.

"Much of the operation of the office of coroner or coroners courts in Australia is centred on injury and death prevention, with the coroner empowered to make recommendations on matters of public health and safety and judicial administration.

Such an approach gives the coroner a dynamic function in contributing to the welfare of the community. As lawyers, Coroners rely upon a range of specialist investigators to provide them with the technical expertise and evidence they need to discharge their responsibilities with regard to the death investigation. These agents of investigation include police, forensic pathologists, engineers, psychologists, physicians and surgeons amoungst others.

Today the medical/pathological aspects of death investigations focused on the pathological examination of the deceased body, is carried out for the most part by full-time forensic pathologists.

Many people think that the Coroner is largely involved in the investigation of suspicious deaths that may have a criminal background such as suspected murders. This is NOT the case. Homicide investigations form a very small part of the work of Coroners perhaps only around 1% of the deaths they investigate. The other 99% of cases reported to a Coroner involve unexplained natural deaths and deaths suspected to be from direct or indirect trauma.

Coroner's courtThe importance of a Coroners’ investigation is that it can lead to a greater understanding of risks and hazards in our community as well as to improvements in public health and safety. By being empowered to hold a public court hearing (the Inquest) Coroners have a vehicle for raising in public the facts about how a person died and can use the inquest to raise awareness of how that death could or should have been prevented.

In conjunction with the work of the Coroner, other statutory agencies including the police, the Chief Medical Officer of Health and the Victorian Institute of Forensic Medicine form a group of ‘watchdogs’ who maintains a constant surveillance on potentially fatal hazards in our society and ensures that preventable deaths are recognised and brought to the attention of the relevant public and government agencies so that the issues surrounding them can be addressed."

Did You Know?

Richard Fidler interviewed Hugh Dillon on 27 November 2018. CAMEO

Hugh retired from his roles as a NSW Deputy State Coroner and magistrate in 2016. He was deeply engaged by his coronial work, and co-authored several important texts.

He is now an Adjunct Professor at the UNSW Law School, as well as undertaking a PhD.

Listen to his story here

Conversations with Richard Fidler


Coroners also investigate the cause and origin of fires and explosions.

In short, the Coroner’s role is to find out what happened, not to point the finger or lay blame.

Following an inquest, coroners may make recommendations to governments and other agencies with a view to improving public health and safety. The Coroner has no power to enforce compliance with such recommendations. It is a matter for the relevant government minister(s) or agencies to determine whether a Coroner’s recommendations should be adopted.

The Coroner may summon witnesses, and people found lying are guilty of perjury. Additional powers of the Coroner include the power of subpoena, the power of arrest, the power to administer oaths, and the power to sequester juries of six during inquests.

Further powers of the Coroner include:

• authorising a police officer or other person to enter any place and gather evidence, similar to a search warrant

• the power to retain possession of the body of a person whose death is reportable to the Coroner. Burial or cremation of such bodies must be authorised by the Coroner.

• clearing court in certain circumstances and preventing publication of certain evidence

• authorising or directing post mortem examinations

• authorising the retention of whole organs (if the coroner is satisfied that the retention is necessary or desirable to assist in the investigation of the manner or cause of the person’s death)

• directing the exhumation of a body for the purpose of a post mortem examination.
(Source: Coroner's Court NSW)

Click here to see the Death Investigation Process


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