The role of the Coroner as outlined in the Coroners Act 2009 is to examine:
- unnatural, unexpected, sudden and suspicious deaths
- suspected deaths (in the case of missing persons)
- fires and explosions that cause serious injury or damage to property.
Coroners also protect lives and wellbeing by bringing to the notice of relevant authorities any practices, policies or laws which could be changed to prevent similar deaths, fires and explosions in the future.
In order to fulfil these roles, coroners rely on information obtained from police, general medical practitioners, specialist forensic pathologists and other specialist physicians, and other experts.
Questions that the Coroner attempts to answer
In the case of a death, the Coroner will attempt to answer all the questions that the death raises:
- Who died?
- When and where did the person die?
- How did the person die?
- What happened and why?
- Is there anything we can do to prevent similar deaths in the future?
And in the case of a fire or explosion:
- What was the cause and origin of the fire or explosion?
The answers to these questions will generally be reflected in the Coroner's findings. In some cases, however, the Coroner may not be able to answer all of the questions and will make what is referred to as an open finding.
If there is doubt about some of the circumstances of the death, fire or explosion, the Coroner may make a finding based on what was most likely to have occurred (i.e. on the balance of probabilities). However, when making a finding of death by suicide, the Coroner must be satisfied beyond reasonable doubt that the deceased intended to take his or her own life.
For a NSW Coroner to have jurisdiction to investigate the circumstances of a death there must be some connection with the State of NSW. This generally means that, at the time of their death, the person must have been:
- ordinarily resident in NSW
- in NSW
- travelling to or from a place in NSW
Jurisdiction to investigate the circumstances of a fire or explosion requires the fire or explosion to have occurred in NSW.
When Coroners in more than one State have jurisdiction to investigate, the respective State Coroners will usually consult each other to determine which State should relinquish jurisdiction to the other. In rare cases inquests into the same death may be heard in more than one jurisdiction.
The coronial jurisdiction is inquisitorial: the Coroner is principally concerned with finding out what happened and how it might be prevented from happening again.
It is not the Coroner's role to aportion blame. Consequently, a coronial inquest or inquiry is not a criminal trial to determine someone's guilt, nor is it a civil trial to determine whether compensation should be awarded (although trials of this nature may certainly occur in other courts following the inquest or inquiry).
If the Coroner comes to the conclusion that a known person has committed a serious offence in connection with the death, fire or explosion, the coronial proceedings must be suspended and the matter referred to the Director of Public Prosecutions who will then decide, independently of the Coroner, whether charges should be laid.