Coronial Inquests

When a loved one dies suddenly, particularly when the circumstances are unusual, violent or the cause is unknown, what the family wants are answers.  Very often this can be achieved through a Coronial Inquest.

Coronial Inquest

Under the Coroners Act 2003, the Coroners Court has a power to hold an inquest to establish the cause or circumstances surrounding a death. Whilst each case is assessed on its own merit, the Coroner has the power to commence an inquest in the event that there has been a reportable death. Any person whom the Coroner considers has sufficient interest in the case may appear in an inquest and is entitled to be legally represented.

Reportable Death

A reportable death includes among other things:

  • where the cause is unexpected, unnatural, unusual, violent or unknown; or
  • a death in custody; or
  • one that occurs during or as a result of certain medical procedures or within 24 hours of such procedures; or
  • a death that occurs within 24 hours of being discharged from hospital; or
  • one that occurs on an aircraft during a flight or on a vessel during a voyage; or
  • where no certificate as to the cause of death has been given.

In the event that a party becomes aware of a reportable death, the South Australia Police and/or the State Coroner must be advised immediately.

In the event that the reportable death is the subject of a police investigation, the South Australia Police will conduct investigations as to the circumstances of the death. If it is determined that the death falls within the meaning of a reportable death, the State Coroner will be advised and an inquest will commence. The Coroner does however have discretions to direct police to seek further information with regard to the circumstances surrounding the death.

Alternatively, the State Coroner can commence their own investigations into the circumstances surrounding the death.

Coronial Inquest

A Coronial Inquest is not held like a regular trial. The process of an inquest is to ascertain the circumstances or causes of a reportable death. However as with any trial witnesses are called who are examined and cross-examined.

The Coroner is a judicial officer whose role is to investigate the circumstances surrounding a death. Once the Coroner has had the opportunity to hear the evidence of the case, they will give written reasons regarding the circumstances of the death and provide recommendations as to how similar situations could be handled in the future.

It is not guaranteed that an inquest will be heard on every reportable death. An inquest is up to the discretion of the State Coroner.


During the coronial process, the Court will call witnesses to provide evidence of their understanding of the circumstances surrounding the death. The Coronial Inquest will not establish whether an individual is culpable for the death. The sole purpose is to fully examine the circumstances of the death. In the event that the death has been caused by negligence of an individual and/or organisation, the decisions do not have any immediate civil implications. Civil proceedings can be commenced after a Coronial Inquest and the findings can be used with regard to the circumstances surrounding liability.

Families are able to instruct solicitors to appear during the Coronial Inquest. This will sometimes assist with the establishment of any liability for any potential resulting civil action and importantly goes a long way to assist with closure.

A strong consideration should be given to legal representation in the event that the death may give rise to any potential civil proceedings, where legal action might be taken against a person or organisation responsible for the death. In the event that the victim’s family has representation, certain questions can be posed to the individual and/or organisation that may be found liable. The coronial process can sometimes narrow the issues in dispute prior to any civil proceedings. Strong consideration should be given to legal representation in the event that a matter proceeds to an inquest.

Websters Lawyers have solicitors experienced in assisting with Coronial Enquiries and can advise you about the costs involved and whether legal funding is available.  Contact us now for a free initial consultation to discuss how we can help you.





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