Related Pages
Related Publications
Web Links and Legislation
The Coroner's Process
The information below outlines a standard coronial process. If you have been affected by the bushfires, please see the information available on the 'Information for Victorians Affected by the Bushfires' page.
The State Coroner's Office is responsible for investigating deaths where the circumstances are sudden, traumatic or unexplained.
Staff at the State Coroner's Office understand the impact this may have on family and friends. Their priority is to investigate the person's death sensitively and professionally, ever mindful of the dignity and privacy of the person who has died and respectful of the family's needs at all times.
Information about the Coroner's Process is also available in the booklet The Coroner's Process - Information for family and friends.
Click on the links or scroll down the page for information on:
What happens in the first 24 hours?
What usually happens after that?
How can I find out what's happening with the coroner's investigation?
What does a coroner's investigation involve?
What happens at the end of the investigation?
What is an autopsy?
Why is an autopsy done?
How long does an autopsy take?
What's in an autopsy report?
What is an inquest?
Why might an inquest be held?
How long does an inquest take?
What is the family's role at an inquest?
Does the family need legal representation at an inquest?
What happens at the end of the inquest?
How do we make funeral arrangements and organise release of the body?
How do I obtain a death certificate?
What are our rights regarding tissue donation?
What happens in the first 24 hours?
Generally in the first 24 hours, a person's body will be taken to the Coronial Services Centre if they died in Melbourne or, in some instances, to a regional hospital if they died in regional Victoria.
You should contact a funeral director to start the funeral arrangements. Tell them the State Coroner's Office is involved.
You may be asked to identify the person.
The coroner will decide whether an autopsy needs to be performed. If so, it will usually happen within three days. If you want to object to an autopsy, contact the State Coroner's Office immediately.
If you are a family member, staff from the Donor Tissue Bank of Victoria may contact you to discuss the option of tissue donation.
The police or coroner's office may contact you to get more information about the circumstances of the death or the person's medical history.
What usually happens after that?
Every coronial investigation is different. It is up to the coroner to decide what investigation is necessary in each case. This may involve:
- a review of the person's medical history and the circumstances of the death
- an autopsy and pathology tests
- specialist reports from experts and external investigators, such as the police, doctors, engineers, the fire brigade, air safety officer, as well as statements from witnesses
- an inquest to test all the evidence relating to the person's death
Most investigations are finalised by the coroner, with a 'finding' based on a review of the available evidence.
How can I find out what's happening with the coroner's investigation?
Any family member can ring the coroner's office to find out what is happening. The funeral director is required to give the coroner's staff the name of a family member as the next-of-kin. The coroner's staff will then list this person on their file as their contact person.
The booklet The Coroner's Process - Information for family and friends will answer many of your questions. If you have further queries, please contact the coroner's office.
Every coronial investigation is different. The investigation may take some time and the coroner's staff will write to you as soon as there is something to report.
You are able to ring the Coronial Services Centre in Melbourne after hours, regardless of whether the death occurred in Melbourne or in regional Victoria.
You can contact the coroner's staff 24 hours seven days a week by telephone on 1300 309 519.
What does a coroner's investigation involve?
It is up to the coroner to decide what investigation is necessary in each case. This can involve:
- a review of the person's medical history and the circumstances of the death
- an autopsy and pathology tests
- specialist reports from experts and external investigators, such as the police, doctors, engineers, the fire brigade, air safety officer, as well as statements from witnesses
- an inquest to test all the evidence relating to the person's death.
Only a small number of investigations result in an inquest. Most investigations are finalised by the coroner, based on a review of the available evidence.
What happens at the end of the investigation?
At the end of the investigation the coroner will write a report (known as a 'finding'). This can vary in length, from a single page to many pages in a case involving an inquest. The finding will be sent to the contact family member, and other people as directed by the coroner. The coroner's finding is a different document from the autopsy report.
If the coroner finishes the investigation and decides there is no need for an inquest, the family and other interested parties will receive a letter telling them that the case is ready to be finalised. They can then have further input into the investigation or request the coroner to hold an inquest, before the case is closed.
What is an autopsy?
An autopsy, or post-mortem, is a detailed physical examination of a person's body after death. An autopsy can help explain why and how the death occurred.
An autopsy is conducted by a pathologist, who is a qualified doctor trained in pathology (the science or study of the causes and effects on the body of disease or damage). The pathologist carries out a detailed external and internal examination of the body.
During the autopsy, the deceased person's body is treated with great respect at all times.
Anyone can write to the coroner asking for an autopsy to be performed, and the coroner will consider that request.
Why is an autopsy done?
In most cases, an autopsy will be necessary to provide medical information about a death.
Occasionally, the coroner can decide the cause of death based on advice about the person's medical history and the police report on the circumstances surrounding their death.
An autopsy provides detailed information about the person's health and gives an understanding of the various factors which may have contributed to their death. Even if the cause of death seems clear, the person may have had a medical condition which was not apparent during their life.
How long does an autopsy take?
The autopsy is usually conducted within three working days of the decision by the coroner to require an autopsy.
This is so that the person's body can be released to the family as quickly as possible and a funeral held with minimal delay. Any additional specialist tests may take up to 10 weeks to complete - the autopsy report won't be finished until they are done.
What's in an autopsy report?
Once the pathologist has all the results of the tests, a detailed report is prepared for the coroner. It outlines the medical findings and conclusions. The coroner takes this information into account when making a finding.
Any member of the person's family, their doctor or their lawyer can request a copy of the autopsy report. The autopsy report is a technical document written using medical terms. If you do decide to get a copy of the autopsy report, it may be helpful to take it to your doctor and ask them to go through it with you.
What is an inquest?
An inquest is a public hearing conducted by a coroner. In Melbourne, inquests are held in the Coroner's Court at the Coronial Services Centre. In regional Victoria, inquests are held at the local Magistrates' Court.
An inquest is not a trial and it is conducted in a more informal way than some court hearings. The coroner has wide powers of inquiry and is not restricted to the normal courtroom rules about what evidence can be given. The coroner may hear from anyone who has information on the death. They can order a witness to attend if necessary.
Why might an inquest be held?
Only a small number of investigations by the coroner end with an inquest. There is always an inquest if:
- homicide is suspected (however, the coroner usually waits until the outcome of any criminal proceedings and can decide not to have an inquest if someone has been charged and convicted of a crime in relation to the death)
- the person was 'held in care'
- the person's identity is not known.
There may be an inquest in other cases if the coroner believes it is necessary. This will usually be because the facts are unclear or there is some issue of public importance (such as public health or safety).
How long does an inquest take?
The length of an inquest varies, depending on the degree of complexity, the number of witnesses and the number of people who have legal representation.
Some inquests last only a few hours, while others can take several days or even weeks.
What is the family's role at an inquest?
The family has an important part to play in the inquest. You may be required to give evidence and there will be an opportunity to express your views to the coroner. You can make a statement to the coroner through the coroner's assistant, through your lawyer or on your own behalf.
Does the family need legal representation at an inquest?
It is not necessary to have legal representation during a coroner's investigation.
However, if you want a lawyer to represent you at an inquest or other court hearing, you will usually have to pay for a private solicitor - the Law Institute of Victoria has a referral service to help you find an appropriate lawyer. You can obtain free legal advice from Victoria Legal Aid or from a community legal centre.
What happens at the end of the inquest?
Once the coroner is satisfied that all the relevant evidence has been heard, they will usually postpone ('adjourn') the case so that they can complete their finding. Sometimes this will be given on the same day, but the case may be adjourned to a future date when the court will be reconvened for the coroner to deliver their finding.
Please note - the Coroner's 'finding' is a public document. You can contact the State Coroner's Office to request a copy
How do we make funeral arrangements and organise release of the body?
You may contact a funeral director as soon as the person has died, without waiting for the coroner to release the body. As soon as the autopsy (if there is one) and identification have been completed, the person's body will be released to your funeral director (usually within three days).
Once you have engaged a funeral director, they will contact the coroner's staff on your behalf to make the necessary arrangements.
The coroner's staff can't recommend a particular funeral director. Your family doctor should be able to help or you can find details in the telephone directory.
You are not obliged to use the funeral director who transported the person's body for the coroner after death.
How do I obtain a death certificate?
Once the medical cause of death is known, the coroner will forward this information to the Registry of Births Deaths and Marriages so that the death may be registered. The registry is responsible for the issue of the official death certificate, which is usually needed for the settling of a person's estate.
Many funeral directors include the cost of the death certificate in the funeral expenses - if so, you will receive the certificate in the mail automatically. If not, you will need to apply to the registry, and pay the prescribed fee, for the issue of the certificate.
What are our rights regarding tissue donation?
Each person whose body is brought to the Coronial Services Centre is considered for suitability as a tissue donor. Transplant coordinators from the Donor Tissue Bank of Victoria contact the family as soon as possible after the person has died because a donation of tissue needs to be made within 12-24 hours of the donor's death.
Consent to tissue donation must be given in writing by the person's most senior next-of-kin. This means, in order of availability:
- the person's spouse or domestic partner
- the person's adult child (18 years or over)
- the person's parent
- the person's adult brother or sister.
If the person who has died is under 18, consent to tissue donation must be given by:
- the child's parent
- an adult brother or sister
- the child's guardian.
It is up to the family to consent to or refuse tissue donation, and the Donor Tissue Bank will always respect the family's wishes.
Contacts
State Coroner's Office
57-83 Kavanagh St
Southbank VIC 3006
Tel: 1300 309 519
Fax: 03 9686 1506