Role of the Coroner

A Coroner is appointed by the Governor-General under the Coroners Act 2006 to investigate certain types of death. A Coroner is a warranted judicial officer, and while they have a legal background, they undertake an inquisitorial process to discover what happened rather than hold a trial to apportion blame.

It is the Coroner's role to:

  • receive notification of a death from the Police;
  • decide whether to direct a post-mortem;
  • authorise the release of the deceased;
  • establish that a person has died, their identity, when and where the person died, the causes of death, and the circumstances of death; and
  • give members and representatives of the immediate family notification of matters required by law.


What is an Inquest?

An inquest is a judicial hearing convened by a Coroner and can be more informal than some court hearings. It is an inquisitorial process to discover what happened rather than to apportion blame.

Why is an Inquest held?

The inquest is held so the Coroner can review all the evidence relating to the death and discover what lessons can be learnt from it. The Coroner will hear evidence from anyone who has information relating to the death. The inquest also enables the Coroner to make recommendations or comments on the avoidance of circumstances similar to those in which the death occurred, or to comment on how other people should act in such circumstances, so as to reduce the chances of other similar deaths occurring.

When is an Inquest held?

The inquest will not be held until all investigations into the death have been completed. This may be an investigation by the Police, the pathologist or any other external investigation that the Coroner has requested or that an outside agency is undertaking.

The family will be advised by the Coronial Services of New Zealand of the time, date and location of an inquest.

A pre-hearing conference may be held with the immediate family to explain the evidence and talk through any issues. Some of the material presented may be detailed and graphic.

How long does an Inquest take?

An inquest can take anything from less than one hour to a few weeks, depending on the complexity of the circumstances surrounding the death.

What happens at the Inquest?

The inquest is usually open to the public. Any person may attend and listen to the proceedings. This may include the media. There are times, however, when a Coroner may exclude people from all or part of an inquest.

The Coroner conducts the inquest, witnesses and experts may be called upon to give evidence or witness statements may be read, and the pathologists report, papers and any other findings may be presented. The immediate family can, either personally or through legal counsel, question witnesses.

The Coroner may make comments on the circumstances surrounding the death and is able to make recommendations, for example, about faulty products or unsafe work practices. If the Coroner intends to make any criticism of the deceased or any other person or body corporate, the Coroner will inform the family or people concerned prior to the release of the findings. This is to ensure they have an opportunity to be heard in relation to the matter, either personally or through legal counsel.

The end of an Inquest

At the end of an inquest, after hearing all the evidence, a Coroner may give either the final findings into the death, or may just announce interim findings. In the latter case, the final findings will be provided in writing at a later date.

Once the inquiry is closed, the Coroner will publish their recommendations. A copy of these will be made available to you and your family.