Go to top of page

The types of deaths the coroner will investigate are called reportable deaths which are generally unexpected deaths or deaths caused by injury or violence.

As well as deaths, the coroner may inquire into disasters where public safety is substantially endangered.

The coroner decides whether or not to hold a public inquest into a death – this is a public court hearing. After the inquest Coroner’s findings about the death are available at

Coroner’s decision page.

Factsheets describing how inquests operate, including audio explanations in Yolngu Matha

Factsheet 1 - Information for families (Audio link in Yolngu Matha)

Factsheet 2 - Information about inquests (Audio link in Yolngu Matha)

What is a reportable death

A death that:

  • appears to have been unexpected, unnatural or violent
  • appears to have resulted, directly or indirectly from an accident or injury
  • occurred during an anaesthetic or as a result of an anaesthetic and is not due to natural causes
  • occurred when a person was held in, or immediately before death, was held in care or custody
  • was caused or contributed to by injuries sustained while the person was held in custody
  • of a person whose identity is unknown

Report a death to the Coroner

Usually a police officer or medical practitioner will notify the coroner of any reportable death.

Every person has a duty to do so if they believe the Coroner may not have been informed.

When a death is reported to the Coroner

When a death is reported to the coroner’s office there are several steps that happen.

These are:

  1. Informing the senior next of kin (family member) that the death has been reported to the coroner.
  2. An autopsy of the person’s body if necessary.
  3. Investigation by Police as to circumstances of death.
  4. A decision on whether or not to hold an inquest.
1. Next of kin informed death has been reported

The first step is that the senior next of kin will be told that the death has been reported to the coroner.

The senior next of kin can be any of the following:

  • the person's husband, wife or de facto partner
  • the person's son or daughter aged over 18 - if the person wasn’t married or their spouse isn’t available
  • the person's parent - if their spouse, son or daughter is not available
  • the person's brother or sister aged over 18 - where a spouse, son, daughter or parent is not available
  • a person who, according to Indigenous customs and tradition of their community or group, is an appropriate person
  • a person who immediately before the death of the deceased person had a relationship with the deceased person that, in the opinion of the coroner, is sufficient for the purpose of being the senior next of kin.
2. When an autopsy of a person’s body is ordered

An autopsy is a medical examination of the body to help find what caused the person’s death.

It is undertaken by a Forensic Pathologist.

The autopsy can sometimes provide evidence of both:

  • disease in the body
  • and/or damage to the body.

The pathologist may take samples of blood and tissue from a person’s body.

In some cases, organs may have to be taken out of a person’s body for special testing.

When the next of kin doesn’t want an autopsy

If the senior next of kin does not want an autopsy on the person’s body, the coroner may (if the Coroner thinks an autopsy is necessary) write to them about the reasons why an autopsy is needed. Where possible, the autopsy will be delayed for 48 hours.

The senior next of kin may apply to the Supreme Court for the autopsy not to be performed.

When an autopsy report is released to the family

The autopsy report is usually not released to the family. An autopsy report is complex and can be easily misinterpreted. However, a copy may be given to the senior next of kin's doctor or some other person able to interpret the report for the family. The family will usually be given the results of the autopsy through the coroner’s findings.

3. Coroner decides whether to hold an inquest

It can take several weeks or months for the coroner to decide whether they will hold an inquest into a person’s death. This is so they can look at all the police and medical reports. If the coroner decides to hold an inquest into a person’s death, they will inform the senior next of kin. Inquests must be held if the person has died in care or custody.

Most other reportable deaths don’t result in an inquest if: 

  • the person’s cause of death is known; and
  • any further investigation won’t provide any further evidence about their death.

If the coroner decides not to hold an inquest

The coroner will give the senior next a kin a copy of their decision about why they are not holding an inquest into their relative’s death. This is known as Inquest Deemed Unnecessary (IDU) findings.

Asking for an inquest to be held as a family member

Family members can write to the coroner about the reasons why an inquest should be held. If the coroner refuses the family’s application for an inquest to be held, they can apply to the Supreme Court within 14 days of receiving the coroner’s reasons.

    Inquests

    An inquest is a court hearing. In the Northern Territory, it is usually held in a court room in the Darwin or Alice Springs Local Court. During an inquest, the coroner hears evidence from witnesses. The inquest may run for a day or a week or several weeks.

    The inquest into the death of Kumanjayi Walker that is underway is being made accessible via a dedicated webpage that includes a livestream of the proceedings.   

    Guidelines

    Guidelines for the efficient operation of inquests

    1. It is a function of the Territory Coroner to ensure that, among other things, the coronial system operates efficiently (s4A(1)(a) Coroners Act 1993).
    2. It is in the interest of families and the community that the Territory Coroner ensures that the investigation, preparation for inquest and assistance throughout the inquest, be as streamlined and responsive as possible.
    3. This guideline provides an overview of directions hearings to be held so as to achieve efficiency, along with a guide to matters likely to be addressed in a directions hearing.
    4. The person filling the role of Deputy Coroner (s5 Coroners Act 1993) will be appointed Counsel Assisting in relation to all deaths in custody and care unless specifically indicated otherwise by the Territory Coroner (s41(2)(b) Coroners Act 1993 and Regulation 11).

    Mandatory Inquests
    Discretionary Inquests
    Findings

    Directions Hearings

    Mandatory Inquests

    5. Directions hearings are likely to be held for all mandatory inquests within three months of reporting such a death (s15 Coroners Act 1993) to the Coroner.

    6. It is expected that the following persons will attend the directions hearing:

    • The officer in charge of the coronial investigation;
    • Counsel Assisting the Coroner;
    • Representatives of institutions or persons who are likely to have a sufficient interest in the death and anticipate seeking leave to appear at the inquest; and
    • Family (if they are willing to attend).

    7. The first directions hearing is to:

    • Ensure the investigation is being conducted in a timely and proper manner;
    • Fix a delivery date for the coronial brief of evidence;
    • Provide any directions as may be considered appropriate including in relation to potential witnesses and the scope of the inquest;
    • Receive submissions on issues that family and others may wish to be explored; and
    • Any other issues the Coroner may consider relevant to the timely progression of the investigation or inquest.

    8. After the coronial brief of evidence is delivered to the Coroner a directions hearing will be held to consider:

    • Applications of persons or institutions seeking leave to appear;
    • Whether any documents or requests for information remain outstanding;
    • Issues that Counsel Assisting and others with a sufficient interest consider should be investigated prior to and/or during the inquest;
    • The scope of those issues;
    • Any documents yet to be provided by interested persons or institutions;
    • The date by which any evidence and responses should be filed by interested persons and institutions;
    • Issues of potential de-identification or restrictions on publication of evidence or other matters of concern to parties;
    • Whether the family have any requirements for further explanation or seek further exploration of identified issues; and
    • Any other issues the Coroner may consider relevant to the timely progression of the investigation or inquest.

    9. Further directions hearings may be held as determined by the Coroner.

    Discretionary Inquests

    10. A directions hearings may be held at any time but will usually be listed after the coronial brief of evidence has been delivered to the Coroner (or earlier, where the time taken receive the coronial brief appears unnecessarily lengthy).

    11. The directions hearing will consider:

    • Applications of persons or institutions seeking leave to appear;
    • Whether any documents or requests for information are outstanding;
    • Issues that Counsel Assisting and those others with a sufficient interest consider should be investigated prior to and/or during the inquest;
    • The scope of those issues;
    • Any documents yet to be provided by interested persons or institutions;
    • The date by which any evidence and responses should be filed by interested persons and institutions;
    • Issues of potential de-identification or restrictions on publication of evidence or other matters of concern to parties;
    • Whether the family have any requirements for further explanation or seek further exploration of identified issues; and
    • Any other issues the Coroner considers relevant to the timely progression of the investigation or inquest.

    12. Further directions hearings may be held as determined by the Coroner.

    Findings

    13. Following the inquest the Coroner will publish Findings. The Findings will be; available at the court when handed down, emailed to family and interested parties who provide their email addresses to the Coroner’s Office, and available online.

    When an inquest is finished

    The coroner will take time to write his decision, this is known as “findings”. 

    This can also be weeks or months depending on the amount of evidence.

    Decisions are available to the public. They are published on the Coroner’s decision page  on the Department of the Attorney General and Justice website.

    Who attends an inquest

    Coroner and lawyers

    The coroner can decide if the following lawyers can attend:

    • a lawyer representing the coroner’s office and community – this person is called counsel assisting the coroner
    • the family of the person who has died
    • an organisation who had care of the person when they died
    • an organisation who had custody of the person when they died
    • another organisation or person connected to the circumstances of the death.

    A lawyer representing the family, another person or organisation is not paid for by the coroner and must be at their own cost.

    Members of the public

    Members of the public and family can sit in the chairs behind the lawyers. Anyone can sit in the courtroom and listen to the evidence.

    In some cases, the coroner may ask people to leave the courtroom and stop some evidence from being published in the media.

    Courtroom rules

    When attending an inquest you should do all of the following:

    • bow to the coroner when entering and leaving a courtroom
    • enter and leave the courtroom quietly
    • not talk, eat or chew gum
    • turn off  your mobile phone
    • remove your hat or sunglasses if they’re resting on the top of your head.

    Witnesses

    Witnesses must attend the inquest if they are asked by the coroner. This is called a summons to appear.

    If they don’t attend the inquest, they can be arrested by police.

    For more information, go to being a witness in an inquest.

    What an inquest investigates

    The inquest will investigate to find out all of the following:

    • the identity of the person who has died
    • the time and place of death
    • the cause of death
    • any relevant circumstances concerning the death
    • other matters connected to the death including public health, safety or the administration of justice.

    The coroner does not decide on issues of criminal liability or civil negligence that may be connected to a person’s death, but may refer it to the Director of Public Prosecutions or Police.

    What happens in an Inquest

    The coroner and persons or lawyers given permission to do so will ask witnesses questions about what they know about the person’s death and the circumstances surrounding the death.

    After hearing evidence from all of the witnesses, each person or lawyer permitted to ask questions may give a summary of the evidence and what the Coroner should make of it, known as submissions.

    The coroner then adjourns the inquest to a later date to write the findings. This can take a matter of weeks or months.

    When the coroner gives their formal findings

    The coroner can take weeks or months to give a decision, depending on the amount of evidence that was included in the inquest.

    The senior next of kin will be told when the coroner is ready to give the decision.

    Family members and anyone else can attend the courtroom on the day the coroner gives their decision.

    Who can get a copy of the coroner’s decision?

    The coroner will give the senior next a kin a copy of their decision.

    Other people can ask for a copy of the findings from the coroner’s office or access it on the website.

    Being a witness in an inquest

    If you are asked to be a witness in an inquest you must attend the court hearing. This is called a summons to appear and is given to you by Police.

    You can be arrested if you don’t attend an inquest.

    If you don’t live in the Northern Territory or you live in a remote area, it may be possible to give your evidence by video link or phone.

    To request this you will have to call the coroner's clerk on (08) 8999 7770 as soon you receive your summons to appear at the inquest.

    Financial help to attend an inquest

    You can apply to be reimbursed for financial loss you have experienced because you have been required to attend an inquest as a witness.

    This includes expenses such as travel costs and lost wages.

    Contact the coroner's clerk on (08) 8999 7770 before the inquest to find out what arrangements can be made.

    What you should bring to an inquest

    You should bring any relevant documents about the death or circumstances of death to the inquest.

    You may be asked to read from documentation, so remember to bring your reading glasses if you need them.

    When you arrive at court for an inquest

    When you arrive at court, the lawyer assisting the coroner will speak with you. They are also called the ‘counsel assisting the coroner’.

    You may sit either outside the courtroom until you are called or inside the court with the consent of the coroner.  

    Sometimes many witnesses may be called and the length of time their evidence takes may be uncertain.

    It is not always possible to be given an exact time that you will be called in court.

    Speak to the counsel assisting the coroner as they may be able to tell you if there will be any delays and what approximate time you will be called into the courtroom.

    Witnesses are also sometimes allowed to sit in the courtroom and listen to the hearing.

    The counsel assisting the coroner will tell you whether you can sit in the courtroom or not.

    When you enter the courtroom

    When you walk into the courtroom, the coroner will ask you whether you promise to tell the truth. If you promise to tell the truth you will say “I do”.

    Giving evidence in an inquest

    You should do all of the following:

    • stay relaxed and calm
    • tell the coroner if you need a break
    • listen carefully
    • ask for an explanation if you do not understand a question or cannot hear a question
    • speak clearly
    • ask the coroner if you are unsure or need advice.

    When you are finished your evidence, the coroner will tell you that you can leave or stay and listen to other witnesses.

    If the coroner decides they want you to come back and give more evidence, you will be asked to return to court to be a witness.

    Witnesses are not informed when the coroner will give their decision. 

    Counsel and family members are told and the findings are published on Department of Justice website.

    Death certificate

    A death certificate is issued after the coroner has issued the findings, or IDU (Inquest Deemed Unnecessary).  

    The coroner will give the findings to the Registrar of the Births, Deaths and Marriages.

    Find out how to apply for a death certificate.

    When a funeral can be arranged

    The family or senior next of kin should appoint a funeral director as soon as possible after a person has died.

    You should contact the coroner's office to find out when the person’s body can be released.

    Find out more information on arranging a burial or cremation.

    Contact the coroner's office

    Coroner’s Office
    GPO Box 1281
    Darwin NT 0801

    Darwin Local Courts
    Nichols Place
    Corner of Cavanagh Street and Harry Chan Avenue
    Darwin NT 0800

    Phone: (08) 8999 7770
    Fax: (08) 8999 5128