Coroner's Inquest

The coroner is a state official who must be either legally qualified or medically qualified, or both, and who makes legal determinations in relation to the cause of death. The central role of the coroner is the investigation and certification of death in circumstances where there is some question or lack of clarity concerning that death, in essence where there are sudden or unexplained deaths.

In many cases the coroner needs to do little more than satisfy themselves that no further inquiry is necessary. However, where necessary they have powers to facilitate a broader investigation or inquest.

The investigation will generally take the form of a post mortem, whereas the inquest is a formal exercise where the coroner, with or without a jury, hears sworn evidence to establish the cause of death without apportioning blame. The object of an inquest, associated as it is with the role of the coroner, is to establish answers to four basic questions:

• Who is the deceased?
• How did the deceased die?
• When did the deceased die?
• Where did the death occur?

The process establishes the facts surrounding the death, places these on the public record and answers the relevant questions. While the coroner may make recommendations to prevent the reoccurrence of such deaths, neither the coroner nor inquest process may establish or apportion any blame for the death which occurred.

There are wide range of cases in which a report must be made to a coroner, and these are determined in law and by local practice. Essentially any sudden or unexplained death must be reported, and even in cases of suspected natural causes where the person has not been seen by a medical practitioner for a month prior to death. For our purposes, most notably, a range of circumstances where deaths are directly or indirectly the result of any surgical or medical treatment, or any procedure, must be reported to the coroner. Further, any death suspected as arising from negligent or violent processes must be reported.

As mentioned the coroner need not investigate or hold an inquest in every case, and if they are satisfied following informal inquiries that nothing untoward has occurred they may direct the issuing of death notification certificate. However, they may conduct further investigations in the form of a post mortem examination, and if satisfied that the cause of death was natural causes may then issue a Coroners Certificate. However, in other circumstances the coroner may decide to hold an inquest.

In most instances the coroner has a discretion as to whether to convene an inquest, however, one must be convened where death is suspected to have occurred in violent or unnatural circumstances or suddenly, and is of unknown cause. An inquest may sit with or without a jury, but a jury must be involved, where:

• Death may be due to homicide (or a suspicious death);
• Death occurred in prison; Death was caused by accident, poisoning or disease requiring notification to be given to a Government Department or inspector;
• Death resulted from a road traffic accident;
• Death occurred in circumstances which may be prejudicial to the health or safety of the public;
• The Coroner considers it desirable to hold an inquest with a jury