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What happens at a coronial inquest?

What happens at a coronial inquest?

This is part four in our series on the Coroners Court. Our previous articles are:

  1. Police are preparing a report for the Coroner. What does that mean?
  2. Reporting to the Coroner - what is a reportable death?
  3. What happens in a coronial investigation?

The inquest is an obvious part of the coronial process. It’s the part that attracts our attention and that of the media.  When there is an inquest of some general interest the media’s catalogue of legal file footage comes rolling out. However, when there is an inquest which keeps a whole country transfixed like the “Inquest into the Death of Chloe Valentine” we get new daily footage and it leads the 6 o’clock news bulletin. 

A coronial inquest is an information gathering process to assist the Coroner in determining the circumstances and cause of a person’s death and if appropriate the Coroner will make recommendations to prevent it a death under such circumstances from happening again. In my opinion this is the most important role the Coroner has. You can read the findings on inquests on the South Australian Courts’ website.

The inquest is a court process. However, generally it is less formal. Witnesses are sworn in or take an affirmation and then they are asked questions. The questions are generally asked by Counsel Assisting the Coroner, who is there to ask questions for the Coroner and assist the Coroner. The Coroner may also ask questions and if other parties have been granted leave to appear they may also ask the witnesses questions.

"Inquests are open to the public and I would recommend you all go and sit in an inquest to broaden understanding."

While witnesses are asked questions it is not the usual trial process most of us are used to. The aim of the Coroner’s Court is to find out what happened, maybe try and stop it from happening again; not to convict anyone or come to a civil judgment. An important aspect of an inquest is the Coroner is not bound by the rules of evidence and this assists with the process of discovery which assists the Coroner to meet the obligations as outlined in the Coroners Act 2003 (the Act).

Inquests are open to the public and I would recommend you all go and sit in an inquest to broaden understanding; as long as you are not too squeamish as the information can, at times be confronting on many levels.

As all deaths are not reported to the Coroner not all reported deaths go to inquest.  If the coronial investigation  answered the questions the Coroner is required to answer then an inquest may not be required or held. Most deaths reported to the Coroner do not actually go to inquest.  In this situation the Coroner will make findings as to the cause and circumstances of the reported death.

If the death occurred in custody an inquest must be held; for example  the death of a prison inmate, a person under a Mental Health Act Involuntary Treatment Order,  a person subject to a police chase or a person surrounded by police in a siege type situation are all considered deaths in custody.  If the Coroner believes the circumstances or cause of a person’s death is of great public importance, an inquest can also be held; as was the case in the Inquest of Chloe Valentine.

Once the Coroner has decided there will be an inquest it is given a date and time. The interested parties, for example next of kin, potential witnesses and/or their lawyers are notified.  If a party wishes to be part of an inquest they can seek the leave of the Coroner to appear either with or without legal representation. If the Coroner is of the opinion that a party has sufficient interest leave is usually granted.

Once the inquest is over and the witnesses have all been questioned Counsel Assisting the Coroner will make submissions to the Coroner as to the cause and circumstances of the person’s death. Then each party that had been granted leave to appear will also be allowed to make submissions as to the cause and circumstances of a person’s death.

The Coroner considers the evidence heard and submissions made.  The Coroner then writes his or her findings as to the cause and circumstances of the death. It is a part of these findings that the Coroner will make the recommendations to prevent a death of a similar type occurring again if appropriate.

While the inquest is not a trial it is still a legal process and we would recommend you speak to an appropriately experienced lawyer if you are summoned to appear as a witness or have an interest in the inquest and want your voice heard and your questions asked. 


Please note, this Blog is posted in Adelaide, South Australia by Andersons Solicitors. It relates to South Australian legislation. Andersons Solicitors is a medium sized law firm servicing metropolitan Adelaide and regional South Australia across all areas of law for individuals and businesses.


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