Coronial inquest

Inquests have been described as “taxing, traumatic, incredibly important and useful”. 

What is an inquest?

An inquest is a court proceeding held by the Coroner to establish the facts around a death or suspected death,  including when, where, and how the person died. The Coroner has legal powers to summon witnesses, request evidence, and make formal findings.

However, the Coroner cannot make findings of criminal guilt or assign legal blame. If issues emerge that suggest criminal conduct, they can refer the matter to the criminal courts.

Families often seek an inquest to:

  • Examine how their loved one’s disappearance was handled
  • Identify whether failures by agencies, or services played a role in their disappearance 
  • Raise missed opportunities or concerns about previous contact with systems
  • Assist with legal matters such as finalising estates, superannuation or insurance
  • Seek information accountability through a formal process

Inquests can also result in recommendations aimed at preventing future harm, though agencies are not legally required to act on them.

Understanding the process

When a person is missing long term and presumed deceased, each state and territory in Australia is legally required to refer the case to the Coroners Court, once all reasonable investigation avenues have been exhausted. This referral doesn’t always lead to an inquest. 

The Coroner will first conduct a coronial investigation and issue a written report to the Next of Kin. This may include information gathered by police, a summary of known facts, and the Coroner’s conclusions about the likely circumstances of death. If no inquest is set, the process will end at this stage unless you request or appeal for an inquest.

Requesting an inquest

Families can request an inquest, but the final decision lies with the Coroner. If an inquest is not scheduled after the initial Coroner’s report:

You can apply to the State Coroner to review the decision. This requires making a formal submission to the court, explaining why an inquest should be held (we recommend seeking legal support for this).

  • You have the right to request written reasons for the decision
  • You can apply to the State Coroner to review the decision. This requires making a formal submission to the court, explaining why an inquest should be held (we recommend seeking legal support for this).

When a Coroner’s Court should hold an inquest

In most states and territories, a Coroner should hold an inquest if:

  • The identity of the person, or the cause or circumstances of death, remains unknown
  • The death appears to have been caused by homicide
  • The person died while in custody or care

When a Coroner’s Court may hold an inquest

A Coroner decides to hold an inquest if:

  • The death raises significant public health or safety concerns
  • There are systemic issues that need to be examined
  • There is significant public interest in holding the inquest 

We strongly recommend seeking independent legal advice before preparing your submission.

Some families also choose to create petitions and raise their concerns with Members of Parliament to support their request.

What to expect

If your request for an inquest is approved and the process begins:

  • You can raise concerns and meet with the Counsel Assisting, who is the lawyer representing the court’s interests
  • With independent legal advice, you may be recognised as an interested party, which means you can:
    • Provide evidence
    • Ask for specific issues to be looked into
    • Request to see the brief of evidence (though this may not always be possible)
    • Request copies of important documents like statements and reports

At the end of the inquest, the Coroner will provide formal findings that may include:

  • The likely cause and circumstances of death
  • Recommendations to help prevent similar situations

While recommendations can highlight important changes, agencies are not legally required to follow them.

Raising issues and making requests

Even if you don’t have a lawyer, you can raise concerns and make requests during the coronial process, including:

  • Asking for an inquest to be held
  • Requesting specific issues be examined
  • Requesting particular witnesses be called
  • Asking to see the brief of evidence
  • Requesting access to investigation materials
  • Requesting emotional support 

Your requests may not always be accepted, but making them known what matters to you and your family is always important.

Preparing

An inquest can:

  • Give you information and answers to questions you may have
  • Confirm concerns or highlight failings
  • Be distressing and taxing
  • Take a long time, often months or years

It’s not easy. We strongly suggest:

  • Making sure you have emotional and practical support
  • Being prepared emotionally before reading or watching anything sensitive

Legal support

The Missed Foundation may be able to connect you with relevant services. Legal aid or pro bono support may be available, depending on your circumstances.

Family information and support by State and Territory:

For more information, please contact The Missed Foundation.

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