How an ACT inquest runs, from report to findings

B.1The coroner and the purpose of an inquest

A coroner is a judicial officer who holds inquests into how and why certain people died. In the ACT, every magistrate is a coroner. An inquest has two aims: to find out how and why the death happened, and to help prevent deaths like it in future.

The coroner decides how wide the inquest goes. That decision rests on what the coroner needs to make findings and on what may reasonably be needed to answer the family’s questions about the death. Whatever the family asks, an inquest can look only at matters likely to be connected with the cause of death.

B.2What the court gathers, and how long it takes

Most of an inquest is quiet work on paper. The court collects and reviews the relevant records and relies on two reports in particular: the pathologist’s post-mortem report, and the investigating police officer’s own report, which may be revised as the inquest goes on. Sometimes the court also asks witnesses for statements or commissions reports from experts.

When the post-mortem report arrives, the coroner considers it and decides whether there is now enough to make findings or whether the investigation needs to go further.

B.3Who keeps the family informed

The court’s Family Liaison Officers are the people to ask for news. A family can contact them at any stage of the inquest. They pass information to the family for the coroner, explain how the process works, and carry the family’s questions and concerns back to the coroner. They can also help in practical ways, such as referring a family to support services or to coronial counselling.

The court’s July 2025 guide for families says the Coronial Counselling Service supports families through the coronial process and for up to three months after the coroner’s findings are issued. The ACT Government Health Directorate funds it, so a family pays nothing for it.

No lawyer is needed to take part in an inquest. If a family does have one, the court expects that lawyer to advise the family about the process and its part in it, and to speak to the court for the family about its views and concerns.

B.4When the law requires more

Three kinds of case run differently from the usual inquest on paper.

A death in custody

The Coroners Act 1997 defines a death in custody in section 3C. It covers, for example, a death at a correctional centre, a lockup or a detention place, a death while someone is being taken into custody, and a death while someone is under certain other orders. If the death happens at an ACT correctional facility, the ACT Inspector of Custodial Services also investigates it, separately from the inquest.

A death in care

Section 3BB defines a death in care. It includes a person who was under a mental health order or held under an emergency detention order under the Crimes Act 1900. It does not include a death in an aged care or disability care facility.

For a death in custody or in care, the coroner must hold a hearing as part of the inquest, and must decide whether the quality of the person’s care, treatment and supervision contributed to the cause of death.

A possible criminal offence

If the coroner believes a criminal offence was committed in connection with the death, the matter must go to the Director of Public Prosecutions, and the coroner stops investigating while the DPP deals with it. No finding the coroner later makes may conflict with the criminal court’s.

B.5If someone is asked to give evidence

A coroner can issue a subpoena requiring a person to give evidence, or to bring a document or thing, at a set date and time. Ignoring one is serious. The coroner may issue a warrant for the person’s arrest; someone arrested this way is brought before the coroner, who may order that they be held in custody or released on a recognisance to come back to court at a set time.

B.6Death certificates while the inquest is open

Certificates come from Access Canberra through the Registry of Births, Relationships and Deaths, never from the Coroners Court. While the cause of death is still with the coroner, the family can hold an interim certificate, and in the ACT that interim certificate is enough proof of death to start probate. The final certificate follows once the inquest ends, and anyone who had an interim one receives the final one automatically. The details are in registering a death in the ACT; the days before the inquest, at the Forensic Medicine Centre, are in when a death goes to the ACT coroner.