If a death has been referred to the coroner, you are likely feeling anxious about what comes next. This guide explains the coronial process in plain language — what happens, how long it takes, and what your role might be.
A coroner is an independent official who investigates deaths that are unexpected, violent, or unexplained. The role exists in Australia, the UK, and New Zealand, though the specific processes differ slightly.
When Is a Death Referred to the Coroner?
A death must be reported to the coroner when:
- The cause of death is unknown
- The death was violent or unnatural (accident, suicide, homicide)
- The death occurred while the person was in custody or detention
- The death was related to a medical procedure or anaesthetic
- The death occurred at work
- The identity of the deceased is unknown
- The death was sudden and unexpected (including sudden infant death syndrome)
The Coronial Process: Step by Step
1. Notification and Initial Investigation
When a reportable death occurs, the police or hospital notifies the coroner’s office. The coroner’s initial investigation determines whether a post-mortem examination is needed and whether the case requires a full inquest.
- Australia: The coroner decides within days whether to order investigations. If the cause of death is clear and natural, the case may be closed quickly
- UK: The coroner opens an investigation immediately. They may order a post-mortem without consulting the family
- New Zealand: Coronial Services NZ assesses each case. Many deaths are resolved without a full inquest
2. Post-Mortem Examination (Autopsy)
The coroner may order a post-mortem to determine the cause of death. This is a medical examination performed by a forensic pathologist.
- In most cases, the family cannot object to a coronial post-mortem
- Results typically take 4–8 weeks, but can take longer
- Tissue samples may be retained for further testing — you can request their return after the investigation
- The body is usually released to the family within a few days of the examination
3. The Inquest Hearing
An inquest is a formal court hearing held by the coroner to establish:
- Who the deceased was
- When and where they died
- How they died (the medical cause and the circumstances)
An inquest does not assign blame or determine criminal or civil liability. Its purpose is to establish the facts.
- Australia: Inquests are held in a coroner’s court. Some states use a jury for certain cases (deaths in custody, workplace deaths)
- UK: Most inquests are held without a jury. A jury is required for deaths in custody, workplace deaths, and some other specific circumstances
- New Zealand: Full inquest hearings are less common. Many cases are resolved through a written report from the coroner
4. The Coroner’s Findings
After the inquest, the coroner publishes their findings, including the official cause of death. The findings are a public document.
- The coroner may make recommendations to prevent similar deaths in the future
- You can request a copy of the coroner’s report from the coroner’s office
- In Australia and NZ, findings are often published online
- In the UK, coroner’s reports are public records
How Long Does the Coronial Process Take?
| Situation | Typical timeframe |
|---|---|
| Simple case, no autopsy needed | 2–6 weeks |
| Autopsy required, no inquest | 2–4 months |
| Full inquest | 6–12 months (sometimes longer) |
| Complex or contested cases | 12–18 months |
During this time, you cannot obtain a death certificate or begin probate. The coroner must release the Medical Certificate of Cause of Death first.
Your Role and Rights as a Family Member
- You will be informed: The coroner’s office should contact you about the investigation. If they don’t, reach out to them
- You can ask questions: You can contact the coroner’s office for updates on the investigation
- You may be a witness: If you have relevant information, you may be called to give evidence at the inquest
- You can attend the inquest: Inquests are public hearings. Family members are entitled to attend
- You can request legal representation: In some cases, particularly if liability may arise, you may want a lawyer to represent your interests at the inquest
- You can make a submission: Most coroners will consider a written statement from the family before making their findings
Legal Options if You Are Concerned About the Circumstances
If the death was caused by negligence, medical error, or unsafe workplace conditions, the coroner’s findings may support a subsequent civil claim. Speaking with a lawyer who specialises in wrongful death or medical negligence can help you understand your options.
This is separate from the coronial process — the coroner does not determine fault or compensation. But their findings are often used as evidence in civil proceedings.