Grief Topic

The Role of the Coroner

Whilst death is part of life, some deaths occur in circumstances where it is difficult to know exactly what happened. Those left behind may have a sense that life was “cut short” and that the deceased person did not have a ‘fair go’. This includes people killed in road and other accidents, by drowning, homicide or lost at sea, where bodies may not be found or may be badly mutilated. Having a knowledge of the facts of the death is very important and may assist in the recovery process.

Reasons to report deaths

In South Australia, (as in all Australian states and territories), the State Coroner must inquire into every death that is reported under the guidelines in the Coroner’s Act (SA 2003).

Deaths that must be reported to the Coroner in South Australia include:

  • Death from a violent, or unusual cause,
  • The cause of death is unknown,
  • A person has died whilst detained in an institution, a prison or in police custody,
  • A person has died during an anaesthetic procedure or within 24 hours of the anaesthetic,
  • A person suffering from mental illness or intellectual impairment dies whilst accommodated in an institution.

The post mortem

A post mortem (or autopsy) is a step by step examination of the outside of the body and the internal organs. It is done by a pathologist to establish the cause of death. A formal identification of the deceased is also required. Arrangements for a funeral can be made, however the burial or cremation cannot be carried out until the Coroner has issued an authority to dispose of human remains. The funeral director will liaise with the Coroner’s Office on behalf of the family.

The Coroner is assisted by people from various government departments who investigate and document each death. In country areas the local police do the investigations. The final report is given to the State Coroner who decides whether an inquest is necessary. Often it will take some time for all of these details to be compiled.

The inquest

In some cases the investigation will proceed further and an inquest (a formal court hearing) will be conducted. The Coroner’s Court operates in an inquisitorial, rather than an adversarial manner, that is, the Coroner can ask questions and actively pursue various lines of inquiry, rather than act as an umpire like judges and magistrates in a traditional court. After an inquest, the Coroner may make recommendations to the various authorities about how certain deaths might be prevented. For example, the SA Coroner has made recommendations about the design of baby’s cots.

Counselling and support services

The following services are provided by experienced social workers at the Coroner’s Office:

  • support immediately following the death
  • information about the Coronial System
  • help in preparing for the inquest
  • information on support groups
  • information on helping children
  • referral to longer term counselling


Page last updated 22nd September, 2016