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Two women grey and white background depicting a discussion about a coronial inquest

When the manner and cause of a person’s death is not clear, an investigation inquest into the circumstances of the person’s death can be held by a coroner. These are called coronial inquests.


A coronial inquest will investigate what happened and make findings to prevent the same thing from happening again.

Elringtons has acted for many ACT and NSW families over the years at coronial inquests associated with medical treatment, workplace deaths, motor accidents and other tragic events.

What is a coronial inquest?

An inquest is a formal court proceeding in which evidence is obtained and presented to the coroner. A hearing may be conducted, though in some cases a hearing is not needed. When a hearing is not needed, the inquest proceeds ‘on the papers’. This means that the coroner considers all documents provided to the court and makes their findings without conducting a hearing.

What types of deaths do coronial inquests investigate?

There are certain deaths that must be reported to a coroner. These include:

  1. When the cause of death is not known;
  2. When a person dies in violent, suspicious or unnatural circumstances;
  3. When a person dies while in custody at a correctional facility;
  4. When a person dies while under a treatment order at a mental health unit; and
  5. When a person dies after undergoing medical treatment and the cause of death appears to be the medical treatment.

What must a coroner decide?

A coroner must investigate the cause and manner of a person’s death. The cause of death refers to the physiological reason, such as a heart attack, systemic shock or multiple organ failure. The manner refers to how the cause of death arose. For example, ‘why did the deceased suffer from systemic shock?’.

Can the coroner make recommendations for public safety?

Yes, this is a key function of a coronial inquest. If matters about public safety arise during an inquest, a coroner can make comments on these issues, including recommendations on what should occur to prevent another death from happening in the same circumstances.

Coronial inquests have a very important function in ensuring lessons are learned from tragic events.

How can a family help the coroner?

A person’s family has a right to participate in a coronial inquest. This means they are able to see the evidence that is provided to the court (by the police, statutory bodies like work health and safety regulators, and court experts). A family may also wish to provide their own evidence and make submissions about what findings a coroner should make.

We have assisted families with:

  1. Obtaining expert evidence;
  2. Drafting witness statements;
  3. Making submissions on the evidence and the findings which should be made;
  4. Appearing on behalf of families at directions hearings and full hearings; and
  5. Dealing with the court, counsel assisting the coroner, and other parties involved with an inquest.

Compensation for family

A coronial inquest does not award compensation to family, though sometimes a person may have died due to the negligence of another. When the family were dependent on the deceased person, we have run successful civil claims based on this loss of dependency and for mental injuries suffered by families. These claims may provide compensation for:

  • Lost income;
  • Lost domestic services such as cleaning, yard maintenance and household chores;
  • Lost care of children;
  • Treatment for psychological injuries (please see our psychological injury page for more information);
  • Funeral expenses; and
  • Distress, grief, suffering and loss of enjoyment of life.

Our team

Our staff have experience in working with families during these traumatic processes. Coronial inquests are intensely personal and it is a privilege to assist families at times of great sadness. We provide compassionate legal services to ensure the deceased person and their family remain front and centre of the legal process.

Tom Maling leads our coronial practice. He is a former Registered Nurse and has experience acting across matters involving public schools, public healthcare, private healthcare, substance use and motor vehicle accidents. Gabby Bridger has a background in psychology and is experienced in working with people who have suffered great loss. Matthew Bridger has been with Elringtons Lawyers for 30 years and has acted for many families over this time in inquests. Isabelle Johnston also acts in matters, particularly those involving healthcare related deaths.

Please feel free to contact us to arrange a consultation about any coronial inquest enquiry you may have.


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