The purpose and scope of coroners’ inquests: introductory guide for practitioners
Produced in partnership with Kevin McLoughlin, Senior Coroner
The purpose and scope of coroners’ inquests: introductory guide for practitioners

The following Corporate Crime guidance note Produced in partnership with Kevin McLoughlin, Senior Coroner provides comprehensive and up to date legal information covering:

  • The purpose and scope of coroners’ inquests: introductory guide for practitioners
  • Reporting deaths to a coroner
  • Understanding the coroners’ courts
  • The structure of the coroner’s courts
  • The legislative framework
  • Terminology
  • Duties of a coroner
  • The purpose of an inquest
  • The scope of an inquest
  • The key features of the inquest process
  • more

Reporting deaths to a coroner

Not all deaths are referred to a coroner. A coroner must be informed that the body of a person is within their area where 'there is reason to suspect' that:

  1. the deceased died a violent or unnatural death

  2. the cause of the death is unknown, or

  3. the deceased was in the custody of the state, ie:

    1. prison

    2. police custody

    3. immigration detention centre

Registered medical practitioners are under an obligation to notify their local senior coroner of a person’s death in specific circumstances. Broadly, the obligation arises if the death is considered by the medical practitioner to be unnatural. Specifically, a death must be referred to the senior coroner if the registered medical practitioner suspects that the person’s death was due to:

  1. poisoning

  2. exposure to a toxic substance

  3. the use of a medicinal product, controlled drug or psychoactive substance

  4. violence

  5. trauma or injury

  6. self-harm

  7. neglect (including self-neglect)

  8. the person undergoing a treatment or procedure of a medical or similar nature

  9. an injury or disease attributable to any employment held by the person during their lifetime

  10. any other circumstances which leads the medical practitioner to suspect that the death was unnatural

The obligation to report also applies where the medical practitioner suspects that the death occurred in custody or in state detention, if they reasonably believe that there