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Coroner's Inquests

Under the Coroners Act 2003 (SA) an inquest can be held to establish the cause, or circumstances, of a reportable death.

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

  • while the person is in custody; or
  • by an unexpected, unnatural, unusual, violent or unknown cause; or
  • on an aircraft during a flight, or on a vessel during a voyage; or
  • that occurs during or as a result, or within 24 hours, of certain medical procedures (some procedures are excluded by the Coroners Regulations 2005 (SA) reg 4); or
  • that occurs at a place other than a hospital but within 24 hours of the person having been discharged from a hospital after being an inpatient of the hospital or the person having sought emergency treatment at a hospital; or
  • of a patient in an approved treatment centre under the Mental Health Act 2009 (SA)

The definition of reportable death also covers other deaths such as some deaths in residential care facilities, deaths of residents in licensed supported residential facilities, deaths in treatment facilities for people being treated for drug addiction, deaths of people who fall under guardianship and other types of protection legislation and where there is no certificate as to the cause of death [see further, Coroners Act 2003 (SA) s 3].

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)].

The State Coroner decides whether an inquest will be held into a reportable death, the disappearance of a person, or into a fire or accident that caused injury to person or property [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).

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)]. 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.

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.

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)].

As soon as practicable after the completion of the inquest the Coroner must give its findings in writing [s 25(1)], this may include recommendations that may prevent or reduce the likelihood of the recurrence of a similar event [s 25(2)]. 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].

Coroner's Inquests  :  Last Revised: Tue Jul 28th 2020
The content of the Law Handbook is made available as a public service for information purposes only and should not be relied upon as a substitute for legal advice. See Disclaimer for details. For free and confidential legal advice in South Australia call 1300 366 424.