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Death Investigation Process

Every death reported to the court is unique and requires and individual investigative approach.

In order to achieve this, the court has established a number of processes that allow different areas of the court and those organisations who provide services to the court, to work together to investigate appropriately throughout the various stages of a coroner's inquiry.

These processes and the various stages of a coroner's investigation into a death are outlined in the flowchart below.


Death investigation process text description

Stage 1 of process

Death reported to the coroner, usually by police of hospitals

Coroner determines whether the death is reportable or reviewable


Deceased person taken into the care of the court.

Coronial Admissions and Enquiries

Receives the police report and other relevant information.
Establishes family contact.
Assists coroner in determining the ‘senior next of kin.’
Facilitates visual or scientific identification of the deceased person.
Facilitates media examination of the deceased person.
Facilitates release of deceased person (for burial or cremation).

Not reportable/reviewable

Doctor prepares Medical Certificate of Cause of Death (no further coronial investigation)

Victorian Institute of Forensic Medicine or Regional Pathologist

Preliminary Examination undertaken and, if directed by the coroner, other medical examinations (e.g. autopsies, identification procedures)
Cause of death provided to the coroner

Stage 2 of process

Court Registry

In a case management meeting, the coroner determines

  1. whether death was due to natural causes, or
  2. whether further information is required – in which case, the court’s Registry will:
    continue family contact, carry out directions from the coroner in relation to the investigation, such as request a Victoria Police member to compile a brief of evidence which may include reports, statements and process requests from family members and other individuals and organisations.

Coroner determines death is due to natural causes.

Notification is given to the reporting party and the deceased person’s family.

Court provides details regarding cause of death to Registry of Births, Deaths and Marriages – for death registration purposes.

Finalised Medial Examiner’s report provided to coroner.

Cause is subject to criminal prosecution. Coronial investigation is suspended until completion of the criminal process.

Coronial brief of evidence compiled by Victoria Police.

Coroner decides whether an inquest is required for their investigation (approximately 5% of the total number of investigations proceed to inquest). Some inquests are mandatory.

Stage 3 of process

A directions hearing is sometimes held.

Coroner decides not to hold an inquest.

Coroner makes Findings with recommendations where appropriate.

Findings with recommendations published in the court website unless otherwise ordered.

A directions prior to the inquest is sometimes held.

Inquest held.

An inquest is a public court hearing.

Coroner makes Findings with recommendations where appropriate.

Findings published on the court website unless otherwise ordered.