Department of Justice

1. What the Coroners Court does

The Coroners Court finds out how and why a person died, and what could prevent a similar death. It does not decide guilt and does not sentence anyone; if a crime is suspected, that is a matter for police and the criminal courts.

2. Reporting a death

Police or ambulance report a death from the person’s file on their tablet. The report goes to the Coroners Court, which opens it for investigation.

Report what you saw and did, plainly. The coroner relies on the first responders’ account more than any other.

3. The investigation

The coroner investigates and keeps notes of what is known as it is learned: who found the person, what responders did, what witnesses saw. In our court the coroner may ask police, ambulance or witnesses to give an account in the city.

In our practice the coroner’s notes usually cover:

• Where and when the person was found, and by whom.
• What police and ambulance did on arrival.
• What witnesses saw or heard before the death.
• Anything that points to how the death could have been prevented.

4. Inquests

An inquest is a hearing in the Coroners Court where the evidence about the death is heard. Inquest sittings are posted in the coroners-court channel.

A death in custody or after police contact must go to an inquest. This is not a finding against police; it is how the department shows the city that such deaths are always examined in the open.

5. Findings

The coroner closes the matter with findings, which set out:

• The cause of death.
• Recommendations: what should change to prevent a similar death.

6. Taking part

Family, friends, police and ambulance may all be asked to give evidence. Treat the court with the respect a death deserves: speak through the microphone when called, stay in character, and keep out-of-character disputes about how the death happened for a ticket.