Coronial Law
Representation at NSW coronial inquests for families after a death and, in separate matters, for organisations, agencies and insurers.
Coronial law covers how a NSW coroner investigates a reportable death, when an inquest is held and what the coroner can find and recommend under the Coroners Act 2009 (NSW). Vamp Law represents families at inquests and, in separate matters, acts for organisations, government agencies, health providers and insurers with an interest in an inquest.
What does a coroner investigate in NSW?
A NSW coroner investigates certain deaths to establish who died, when and where, and the manner and cause of death (Coroners Act 2009 (NSW), section 81). A death must be reported if it is a reportable death (sections 6 and 35):
Violent or unnatural deaths
such as homicide, suicide or poisoning.
Sudden deaths
where the cause is unknown.
Suspicious or unusual deaths
where the circumstances are suspicious or unusual.
Deaths after health care
where the death was not the reasonably expected outcome of a health-related procedure.
Mental health facility deaths
of a patient in, or temporarily absent from, a declared mental health facility.
Deaths in custody or as a result of a police operation, and some deaths of children and people with disability, must also be reported (sections 23, 24 and 35). Coroners can also inquire into fires and explosions that destroy or damage property in NSW (section 30).
Vamp Law represents families at inquests as part of its personal injury practice and, in separate matters, organisations, agencies, health providers and insurers. It never acts for a family and an organisation in the same inquest, and a conflict check is run on every new matter.
When does a coroner have to hold an inquest?
An inquest must be held where the person may have died as a result of homicide (not including suicide), died in police or other lawful custody or as a result of a police operation, or where it has not been sufficiently disclosed whether the person died, their identity and the date and place of death, or the manner and cause of death (section 27). The Minister or the State Coroner can also direct one (section 28).
Otherwise the coroner has a discretion, and most reported deaths are finalised without an inquest (section 25). Inquests into the deaths of children in care, and some other deaths of children and people with disability, are reserved to the State Coroner or a Deputy State Coroner (sections 22 and 24), but are not automatic.
Can a family object to a post mortem examination?
Yes. The senior next of kin can ask the coroner in writing not to direct a post mortem examination (section 96). That is, in order, the spouse or partner, an adult child, a parent, an adult brother or sister, then an executor or legal personal representative (section 6A), and they can authorise someone else in writing, such as a lawyer, to act for them (section 98). The Coroners Court asks for the objection promptly, with reasons, including any cultural or religious beliefs.
If the coroner still decides the examination is necessary or desirable, written notice must be given of the earliest time it can happen, at least 48 hours later, and of the right to apply to the Supreme Court. That application must be made within 48 hours of the notice, and making it puts the coroner's direction on hold (section 97). A similar process applies to keeping a whole organ, and whoever conducts an examination is to try to use the least invasive appropriate procedure (section 88).
What can a family do if the coroner decides not to hold an inquest?
A family can ask for one, and can take further steps if the answer is no.
Ask in writing
The coroner takes a family's reasons into account, but the decision is the coroner's.
Ask for reasons
A person the coroner considers has a sufficient interest can ask for written reasons for dispensing with an inquest, and the coroner must give them (section 26).
Ask the State Coroner
The State Coroner can review the decision and direct that the inquest be held (section 29).
Apply to the Supreme Court
The Court can order an inquest where that is necessary or desirable in the interests of justice (section 84).
Who can take part in an inquest and question witnesses?
Anyone the coroner considers has a sufficient interest can be given leave to appear, in person or through a lawyer, and can then examine and cross-examine witnesses on relevant matters (section 57). A relative, meaning an adult spouse or partner, parent (or someone in a parent's place), guardian or child or, failing them, an adult brother or sister (section 5), must be given leave unless exceptional circumstances justify refusing it.
A person with leave can ask the coroner to call a particular witness (section 60). For families, Kyra Pastrovic explains the evidence, questions the witnesses who matter most to them and makes submissions on the findings.
What can a coroner find and recommend?
At the end of an inquest the coroner records whether the person died and, if so, their identity, the date and place of death, and the manner and cause of death (section 81). The findings must not indicate or suggest that anyone committed an offence. The coroner can make recommendations on any connected matter, including public health and safety, and can direct them to government agencies and other bodies (section 82).
A coroner cannot enforce a recommendation, but under NSW Government policy (Memorandum M2009-12), ministers and agencies are expected to report to the Attorney General within six months on the action they are taking, or why not.
If someone is charged with an indictable offence raising whether they caused the death, the coroner must suspend the inquest once the death, identity, date and place are established. If the evidence could satisfy a jury beyond reasonable doubt that a known person committed such an offence, with a reasonable prospect of conviction, the coroner can suspend or continue, and the evidence goes to the Director of Public Prosecutions (section 78).
How does Vamp Law act for organisations, agencies and insurers at an inquest?
Vamp Law acts for bodies whose people, systems or decisions are examined at an inquest. Kyra Pastrovic has a lengthy history representing state government agencies, commissioners, politicians, premiers and other departmental heads, alongside some of Australia's largest insurance companies.
The work includes seeking leave to appear, responding to a notice to produce documents such as medical records (section 53) or a subpoena (section 66), and preparing statements and witnesses. Where recommendations are being considered, Vamp Law puts factual submissions on whether they are workable. The approach stays factual throughout.
Frequently asked questions
No. An inquest is not a civil trial. The evidence it gathers, such as statements, medical records and the transcript, can still help a family understand whether a claim exists, as the wrongful death and medical negligence claims pages explain.
The time limits for a claim run separately from the coronial process.
No. A family can take part without one, and the lawyer assisting the coroner can sometimes ask questions on its behalf. Some families choose their own lawyer because the evidence can be technical and distressing.
The Coroners Court says some investigations take a few months and others twelve months or longer, and a post mortem report can take more than a year to be available.
An inquest can last from an hour to many weeks.
A family can ask for copies of material on the coroner's file, such as statements, reports and transcripts. The coroner decides whether release is appropriate, having regard to matters including the impact on the relatives, and a fee applies (section 65).
Speak with Vamp Law about a coronial inquest
This page is general information about NSW law, not advice on your situation, and the right answer depends on the facts and the documents. When you are ready, make an enquiry or call +61 431 569 686 to speak with Kyra Pastrovic.
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