LawTalk Blog

What happens in a coronial investigation?

What happens in a coronial investigation

This is part three of our series on the Coroner.  The first two blogs will help provide a foundation for this article so you may want to have a quick read.

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

So the death of a person you hold so dear has been reported to the Coroner. What happens from here is the coronial investigation. The first thing you’ll need to know about this step is it can take some time. It’s a question of the Coroner’s need to get this step right, to do the investigation well, and it wouldn’t hurt for our government to provide the Coroner with a few more resources.

After a death has been reported the Coroner must decide if it is necessary to hold an inquest to whom, how, why and when the person died.  The inquest is a step in the investigation process but not always necessary, warranted, or desired. To make the decision as to whether to hold an inquest the Coroner begins the investigation.

Step one

The death of the person is certified by a doctor or qualified paramedic.

Step two

The person is identified usually by someone who knew them well. Sometimes it may require things like fingerprint testing or DNA testing.

Step three

The Coroner may need to order a post mortem or autopsy to establish a cause of death. Sometimes this can take time. The pathologist who undertook the autopsy will then prepare a report for the Coroner. This step can also take time while the results of toxicology tests and other tests are provided.

"If the Coroner asks police to gather information it does not mean anything criminal or suspicious has occurred. "


Throughout this process the Coroner may be directing police to gather information to assist with the investigation. Police do things like obtain statements from witnesses to the death or provide forensic crash reports in relation to motor vehicle accidents.

If the Coroner asks police to gather information it does not mean anything criminal or suspicious has occurred. Police have the skills needed to speak with witnesses and obtain statements. The Coroner obtains the statements so there is a solid foundation on which to make a decision as to whether an inquest is needed or not. Once police have obtained the statements and other material needed they then prepare a report for the Coroner.

The Coroner can also obtain reports from experts. Experts’ reports can be on almost any issue. A doctor may provide a report on a medical issue; a psychiatrist on a mental health related death; an engineer would provide a report on the collapse of a building or bridge; the list is endless. The expert involved will depend on the person who has died and the circumstances of their death.

In the Coroners Act 2003 there are some deaths whereby an inquest must be held; for example a death in custody (including a person being detained under any Act or law) or where the Coroner thinks it is desirable to hold an inquest. If an inquest is to be held, a date is set and interested parties (like family, witnesses, etc) are advised.

If there is no inquest to be held then the Coroner will make his or her findings into the reported death.

If you and your family are going through this process and want legal advice, you need a particular type of lawyer; one experienced in dealing with Coroner’s matters. It is important to remember the Coroner’s Court is an inquisitorial process and not a Court process we are all used to here in South Australian; the adversarial system. Make sure any lawyer you speak with knows and understands the Coronial process. 

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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