Coronial Inquests, Autopsies and the law

Contributed by Isabel Roper and current at 16 December 2021.

Relevant legislation

The governing Act in the ACT is the Coroners Act 1997 (ACT). All references to specific sections are references to this Act.

What is the Coroners Court?

In the ACT, the Coroners Court is the name for the specialist court run by a coroner that investigates deaths, fires and disasters. Unlike in some larger states, all ACT magistrates are coroners (s 5) and the Chief Magistrate is the Chief Coroner (s 6).

As part of its role in investigating deaths, the Coroners Court is also responsible for making recommendations to prevent deaths, increase public safety, for the administration of justice, or for further investigation by other bodies (s 3BA(1)(d)). The Court keeps a comprehensive record of coronial findings and recommendations (s 3BA(2)(c)).

The Coroners Act requires that coroners answer all reasonable questions from family members about a death under investigation and keep the family informed as far as it practical (s 3BA(2)(a)).

Coronial investigations are also called ‘inquests’.

What is a coronial investigation or inquest?

The coroner must investigate the deaths of people that lived in the Australian Capital Territory if the deaths are one of the following types (s 13):
  • violent or unnatural deaths;
  • deaths after medical procedures;
  • deaths caused by accidents;
  • deaths of people who have not seen a doctor in 6 months;
  • deaths where a doctor has not granted a certificate stating the cause of death;
  • deaths in custody;
  • deaths in suspicious circumstances.
Someone who knows that a death has happened and believes it is a type of death the coroner would investigate must report it to a coroner or police officer (s 77). When someone dies in custody, their death must always be reported to the coroner by a custodial officer (s 78).

Most deaths are investigated by the coroner using written reports from doctors, police and other bodies. A coroner will hold a court hearing for approximately 5 percent of investigations. The coroner must hold a hearing where a person has died in custody (s 34A(2)).

ACT coroners investigate approximately 350 deaths each year and hold approximately 10-15 inquest hearings.

The coroner also investigates fires, if they think an inquiry is needed or the Attorney-General asks them to (s 18(3)(b)). If someone whose property has been damaged in a fire asks a coroner to investigate and the coroner decides not to, the coroner must provide written reasons for their refusal (s 18). If the Attorney-General asks the coroner to do so, they must investigate a disaster (s 19).

Post-mortem examinations

Post-mortem examinations, also known as autopsies, can help a coroner establish a cause of death. The coroner can decide to order a post-mortem examination (s 19). Family members of the deceased can request that a post-mortem is not carried out (s 20(2)), but the coroner may refuse this request if the cause of death is not sufficiently clear.

The coroner must consider if there are religious or cultural reasons why a post-mortem exam would not be appropriate (s 17A). They will consider the need to minimise distress or offence to the family where that is possible.

Family members can request: If the coroner refuses a request of this type, the coroner will refuse in writing and include an explanation for the refusal (s 23(2)). The family member may apply to the Chief Coroner then, who may ask the coroner to reconsider their decision. (s 23(3)).

Coronial powers

Like a judge, a coroner can do many things to investigate a death or fire. For example, the coroner can issue search warrants (s 66), order that the court keeps and inspects objects that may be evidence (s 67), order people to attend court to give evidence as witnesses (s 43), declare a place is a coronial investigation scene (s 68C), or appoint a lawyer or police officer to help them investigate (s 39A/s 59/s 63).

Inquest hearings

The coroner may decide to hold a hearing as part of an inquest. In some ways this is like other types of court: witnesses give evidence under oath and are asked questions by a lawyer assisting the coroner (s 48). Like court, hearings are generally public (s 40). Family members and other parties (such as hospitals) may hire lawyers to represent them and ask questions for them at the hearing (s 42).

However, inquest hearings are different from other court hearings in several ways. The coronial system is 'inquisitorial' rather than 'adversarial': some rules of evidence are relaxed (s 47), there are no 'successful' or 'unsuccessful' parties and the coroner can protect people who give evidence from being prosecuted, if their evidence shows they have done something unlawful (s 51B). These differences aim to assist the coroner in discovering the truth about a death.

If the coroner decides to hold a hearing, they will inform the immediate family of the deceased (s 68A). Expert witnesses like medical or safety specialists may give oral evidence to the coroner with the help of counsel assisting (a lawyer appointed to assist the coroner in court). In the course of the hearing, the court may visit the scene of death.

A hearing may be suspended if the coroner suspects an indictable (punishable by more than two years' imprisonment) offence has been committed. In this case the coroner will refer the matter to the Director of Public Prosecutions. The hearing will not recommence until a decision has been made about whether to prosecute the relevant person for the alleged offence, or a certain amount of time has passed (s 58A). The coroner may also suspend a hearing to wait for more evidence to be available.

Coroner's findings

The coroner writes a set of findings after they finish investigating a death (s 52). If there was no inquest, the findings may be short. The findings must state who the deceased was, when and where they died, and the manner and cause of their death (s 52).

Where the coroner has held an inquest, the findings may be complex and may not be published for some months after the inquest ends (s 52). In these cases, the coroner may hand down some interim, or preliminary, findings, at the end of the inquest (s 53).

Findings are not always published on the ACT Magistrate's Court website. If you are a family member of the deceased, you can request a copy of the findings from the Coroner's Court Registry (s 54).

Deaths in custody

When someone dies in custody the coronial investigation is slightly different.

The coroner must not conduct a hearing unless they have tried to notify immediate family and, if the deceased was an Aboriginal or Torres Strait Islander person, notified the local Aboriginal legal service (s 69).

If family members request it, they must be allowed to view the body, post-mortem or death scene unless the coroner believes it is not in the interests of justice (s 70). The coroner must make findings about the quality of the care, treatment and supervision of the deceased if these things contributed to the death (s 74).

Finally, the place where the deceased was in custody must respond to the coroner's findings within 3 months by reporting to the Minister (s 76).

Further information

Further information can be found on the Coroner's Court section of ACT Magistrates Court website at

The court can be contacted by post, phone or email:

Coroner's Court Registry
The Registrar, Coroner's Court,
GPO Box 370,
Canberra ACT 2601
Phone: (02) 6207 1754
Fax: (02) 6205 9589

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