Under the Coroners Act 2003 (SA) an inquest can be held to establish the cause, or circumstances, of a reportable death. The circumstances may include matters related to or arising out of the event or its aftermath [s 3(3)].

Reportable death is defined in section 3 of the Coroners Act 2003 (SA). It includes the death of a person:

A death that occurs as a result of medication administered in accordance with the Voluntary Assisted Dying Act 2021 (SA) is not a reportable death [Coroners Act 2003 (SA) s 3(1)].

Immediately after a person becomes aware of a reportable death they must notify police or to the State Coroner of the death, unless the person believes on reasonable grounds that the death has already been reported. Failure to do this is an offence, maximum penalty $10,000 or imprisonment for 2 years [s 28(1)].

If the State Coroner is notified under this Act of a reportable death, a finding as to the cause of the death must be made by the Coroner's Court if an inquest is held, or by the State Coroner [s 29(1)].

However, the State Coroner may make a finding that a death was due to undetermined natural causes if they have obtained relevant medical information or advice, and have reasonable grounds to believe that the death was due to natural causes. The deceased person's senior next of kin must also give their written consent to no further action being conducted for the purpose of determining the precise cause of death. Section 29(3) of the Act defines a senior next of kin to include a spouse, domestic partner, adult children, parents and adult siblings.

The State Coroner decides whether an inquest will be held into:

[see Coroners Act 2003 (SA) s 21].

However, the Attorney-General may also direct the Coroner to hold an inquest into a particular case. The Coroners Act 2003 (SA) requires that an inquiry must be held where there is a death in custody, which is defined in section 3(1) of the Coroners Act 2003 (SA). For this purpose, a death in custody includes the death or apparent death of a person from natural causes (as certified by a medical practitioner) while subject to an inpatient treatment order under Part 5 of the Mental Health Act 2009 (SA) and held in a dedicated mental health ward of a hospital or other approved treatment centre facility [s 21(4)].

An inquest is an informal hearing, however the Coroner’s Court has many powers, including the ability to summon people before the Court and require people to swear that they will truthfully answer questions [see s 23(1)(c)]. However, if a person objects to answering a question, or producing a record or document on the ground that the answer, record or document may tend to incriminate the person or make the person liable to a penalty, then the Court must determine whether or not there are reasonable grounds for the objection [see s 23A]. The Court may issue a certificate limiting when such evidence can be used, if the Court finds that the person is still compelled to give evidence. Legal advice may need to be sought in such circumstances before appearing at an inquest.

A person is not required to answer a question, or to produce a record or document at an inquest if answering the question, or producing the record or document, would result in a breach of legal professional privilege [ s 23(5)].

If a person has been charged with a criminal offence of causing the event that is to be inquired into the Coroner may not proceed until the criminal proceedings have been disposed of [s 21(2)].

Any person the Coroner considers has a sufficient interest may appear in an inquest. The facts are established by calling witnesses who are examined and cross-examined and documentary evidence may be tendered. A nominated representative (a legal practitioner) of the family is entitled to appear in those proceedings and may examine and cross-examine any witness testifying in the proceedings [s 20A].

The Coroner is not bound by the normal rules of evidence and may inquire into any issues as she or he thinks fit. The Coroner must act according to equity, good conscience and the substantial merits of the case, but without regard to technicalities and legal forms [see s 24]. However, the normal rules of natural justice and procedural fairness still apply.

As soon as practicable after the completion of the inquest the Coroner must give its findings in writing, which may include recommendations (as appropriate):

[s 25(2)].

There are reporting requirements for any recommendations the Coroner makes. Each relevant minister (or if there is no relevant minister, the SA Attorney-General) must, within eight sitting days of the expiration of six days after receipt of a copy of a recommendation resulting from an inquest:

The State Coroner may, at any time after the provision of the report, request a supplementary report to be prepared by the relevant minister (or Attorney General) that addresses any matter the Coroner considers necessary arising out of the report. If the Coroner makes a request, then the relevant minister to whom the request is made has eight sitting days after receiving the request to cause a supplementary report to be laid before each house of the parliament and forwarded to the Coroner.

However, the Coroner must not make any finding or suggestion of criminal or civil liability [s 25(3)].

The Coroner may reopen an inquest at any time or the Attorney-General may direct that an inquest be reopened. On the application of either the Attorney-General or a person who has a sufficient interest in the finding, the Supreme Court may order that the Coroner's finding be set aside, be reopened, that a new inquest be held, or substitute other findings which appear justified on the evidence. Any application must be made within one month after publication of the finding although the Supreme Court has a discretion to allow a longer time [see generally, ss 26 - 27].