11 Things You Need to Know About the State Coroner’s Guidelines

Coroners are responsible for investigating reportable deaths in Queensland. The State Coroner’s Guidelines Queensland 2013 is a comprehensive document outlining the role and responsibilities of the Coroner.

Coroners are bound to comply with these guidelines and any further directions issued to them to the greatest practicable extent.

Chapter 9 of the State Coroner’s Guidelines Queensland explains the decision-making process for a coroner when deciding whether to proceed with an inquest. It outlines the process of an inquest and strategies a State Coroner uses in preparing, managing, and conducting an inquest in Queensland.

This article explains key components of Chapter 9, including when a coronial inquest should be held, how to request an inquest, and the role of Counsel in a coronial inquest.

1. What is a Coronial Inquest?

A Coronial Inquest is a public hearing held to determine the medical cause of death and explore the circumstances surrounding it. It examines events leading to a reportable death.

A Coronial Inquest may also be called when there are multiple deaths in a short period. However, not all reportable events proceed to an inquest. Only a small percentage of the total deaths reported to the Queensland Coroner each year will go to an inquest.

Coronial inquests, along with a coroner’s comments, can be catalysts for systemic changes. Queensland Coroners may make recommendations regarding matters connected to the death, including public health and safety, and the administration of justice.

2. When Should a Coronial Inquest Be Held?

In Queensland, a coronial inquest should be held if it serves the public interest or if there is reasonable doubt about the cause or circumstances of a death. Coroners can use their discretion to determine whether an inquest is necessary.

A coronial inquest must be held in certain circumstances, including:

• Deaths in custody
• Deaths during police operations that raise significant concerns
• Deaths in care where the quality of care is in question
• When directed by the Attorney-General or the State Coroner
• When the District Court upholds an appeal against a coroner’s decision not to hold an inquest

3. The Right to Request an Inquest

Under the Coroners Act 2003 (Qld), any person has the legal right to request an inquest into a reportable death, including family members of the deceased. The coroner has six months to respond, unless additional witness statements or expert reports are needed.

If an inquest is deemed unnecessary, the investigating coroner must provide reasons for declining the request. Family members will typically receive 14 days’ notice of the coroner’s intention to finalise the investigation without an inquest. A court application can be made to appeal this decision.

4. Communicating Decisions to Hold or Not Hold an Inquest

All interested parties must be informed of the coroner’s decision to hold or not hold an inquest. Family members should receive a “Form 26” document and a covering letter outlining the reasons for the decision. If the coroner declines to hold an inquest, the decision can be reviewed by the State Coroner or the District Court.

5. The Role of Counsel Assisting in a Coronial Inquest

Coroners are supported by in-house lawyers who assist in managing investigations and often appear as Counsel Assisting at inquests. External counsel may be engaged for more complex cases to help review the available evidence.

Counsel Assisting acts impartially, presenting evidence to the coroner, examining witnesses, and making submissions on the findings. However, the coroner ultimately weighs the evidence and makes the final decision.

6. Notification of Inquests

Anyone with a legitimate interest in a Coronial Inquest must be notified of its date, time, and place. Additionally, the commencement date must be published in the Courier Mail newspaper to inform the public. The senior family member of the deceased should also receive written notice.

If the deceased is of Aboriginal or Torres Strait Islander descent, the local Aboriginal and Torres Strait Islander Legal Service must be informed, unless otherwise advised by the solicitor or family.

7. Preparing for an Inquest

Before a pre-inquest conference, Counsel Assisting prepares a list of proposed issues and witnesses for the coroner’s consideration. This information is shared with the family and other relevant parties. Counsel Assisting and the coroner often meet with the family to explain the inquest process and scope.

8. Pre-Inquest Conferences

While not mandatory, pre-inquest conferences are common and help ensure inquests are completed in a timely manner. Matters discussed include the evidence, witness lists, applications for leave to appear, venue, and non-publication orders.

9. The Scope and Conduct of an Inquest

The coroner’s role is unique, as they are not bound by formal rules of evidence or procedure. However, inquests must follow the principles of natural justice and procedural fairness. Inquests can be stressful for both the family and witnesses, and coroners must ensure the process is efficient.

In general, a Coronial Inquest is held in open court, unless there are good reasons for a closed hearing.

10. Inquest Findings and Comments

Coroners have the authority to make recommendations to prevent future deaths. These recommendations often relate to public health and safety or the administration of justice and must be realistic and workable. The relevant agencies are typically consulted to ensure that the recommendations are feasible.

11. Review of Inquest Findings and Reopening Inquests

A coroner’s findings can be appealed to the State Coroner or the District Court. The findings can be set aside if new evidence emerges, the finding was incorrectly recorded, or if the evidence did not support the original conclusion.

Contact Medical Law Today

Understanding the State Coroner’s Guidelines is essential if you’re involved in a coronial inquest or believe a death was mishandled. At Medical Law, we provide expert legal advice on navigating coronial inquests and ensuring the proper application of the State Coroner’s Guidelines. If you have concerns about a reportable death or need assistance with the inquest process, contact Medical Law today to protect your rights and get the guidance you need. Let us help you through this complex process with professional support and legal expertise.