Following the investigation of a death, there are a number of possible outcomes:
- The Coroner dispenses with an inquest (decides not to hold one)
- An inquest is held and the Coroner delivers findings
- An inquest is held and the Coroner delivers findings with recommendations
- An inquest starts and is suspended by the Coroner
In most cases the Coroner will dispense with the inquest. This means that the Coroner is satisfied with the identification of the deceased person, the date and place of death as well as the manner and cause of death. It is not necessary to hold an inquest and the Registry of Births, Deaths and Marriages can issue the death certificate with the cause of death.
Investigations of nearly all deaths that are reported to the Coroner are completed without the need for an inquest.
Other deaths may require an inquest, either because it is mandatory to do so under the Coroners Act 2009 or the Coroner believes there is a need to hold an inquest to further investigate the death.
If an inquest is held, the Coroner will make a formal finding at the end of the inquest. A finding is a narrative outlining what the Coroner has decided in the matter. The length of a finding can vary from a single page to numerous pages depending on the complexity of the investigation. The finding will be delivered in court by the Coroner.
The Coroner may also make recommendations to public authorities with the aim of preventing similar deaths in the future. For more information, read about the Coroner's jurisdiction.
In some cases, the Coroner may form the view that a known person may have contributed to the death, and there is sufficient evidence to refer the matter to the Director of Public Prosecutions (DPP). If the Coroner forms this view during or at the end of an inquest, the Coroner may suspend the inquest and refer the inquest papers to the DPP. The DPP will then consider whether to pursue indictable charges against that person.
The Coroner must also suspend the inquest if he or she is advised that a person has been charged with an indictable offence connected with a death. In this case the Coroner will refer the coronial file to the DPP.