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The Court

Every death and fire reported to us and investigated by a coroner is unique.

Our court is made up of several areas that enable us to fully investigate the death or fire during every stage of the coronial process.

Legal Services

Our Legal Services assist coroners with their investigations by analysing evidence, preparing draft findings, preparing matters for inquest and appearing as counsel to assist the coroner at inquests.

Legal officers assist coroners with the coronial investigation by drafting legal documents and correspondence on behalf of the court, attending court hearings when required and communicating directly with families.

Coroners Prevention Unit

The Coroners Prevention Unit (CPU) is a specialist service for coroners created to strengthen their prevention role and provide them with expert assistance by:

  • reviewing a range of reportable and reviewable deaths
  • collecting and analysing data relating to reportable and reviewable deaths
  • assisting coroners in the development of prevention-focussed coronial recommendations
  • receiving and publishing recommendations.

The central goals of the CPU are to:

  • improve the quality and applicability of coronial recommendations
  • increase the uptake and implementation rate of coronial recommendations
  • contribute to the reduction of preventable deaths in Victoria.

The CPU may contribute at any stage of the coronial process, including:

1. When a death is initially reported – through the provision of advice that can be used by coroners to:

  • decide on the direction of the investigation
  • ensure that essential data is gathered
  • identify any prevention opportunities relevant to an individual case.

2. When recommendations are being developed – through the provision of advice to coroners on:

  • the nature and extent of causes and risk factors
  • up-to-date evidence on countermeasures
  • identification of relevant stakeholders who may be affected by the recommendations
  • information on relevant sections of legislation, standards and codes of practice
  • information on similar previous cases and recommendations.

3. When recommendations are being finalised – by engaging with relevant stakeholders at the direction of coroners to ensure that any proposed coronial recommendations are reasonable, viable and likely to be effective.

After recommendations have been made – by monitoring and collecting information on the responses to and implementation of coronial recommendations.

Additionally, the CPU undertakes both individual and collaborative research projects to generate a better understanding of preventable deaths in Victoria and identify intervention opportunities.

Coroners Support Services

The Coroners Support Service provides administrative support to coroners after the initial phase of the investigation is completed by staff at Coronial Admission & Enquiries and the person is released for the funeral.

The Coroners Support Service consists of coroners’ registrars, court administration officers, Aboriginal Engagement Unit and family liaison officers who are the primary source of information and contact with the senior next of kin, families, interested parties, the public, police, health service providers and many other departments and agencies.

Coroners Support Service staff process a coroner’s directions and orders and ensure that relevant people or organisations complete them. This may include seeking further statements on behalf of the coroner, or organising medical expert opinions, or listing a case for hearing in open court.

They also regularly speak to Victoria Police, the Victorian Institute of Forensic Medicine (VIFM), hospitals, doctors and other government departments or agencies to ensure that any information required by the coroner is provided as soon as possible.

Providing information and updates to families through letters and phone calls is also a crucial function of the Coroners Support Service. Letters are sent to family members at key points during a coroner’s investigation. These letters provide updates regarding the cause of death, how the coroner intends to investigate and whether any further medical investigations are required.

Registrars assist coroners with the coronial investigation by providing administration support, coordinating court hearings including inquests, direction hearings, mention hearings and the delivery of findings. They also attend court hearings when required and communicate directly with families.

Court administration officers assist the coroners by undertaking general administration, maintaining various records and registers and attending court hearings when required.

The Aboriginal Engagement Unit consists of Aboriginal team members to provide cultural support and directly communicate with Aboriginal families during the coronial process. This includes the Aboriginal Engagement Unit attending court hearings with Aboriginal families to ensure cultural care is delivered throughout.

Family liaison officers assist coroners with investigations where families and witnesses require additional support during the coronial process. This includes delivering sensitive information on behalf of coroners and other stakeholders, helping families understand information contained within a coronial brief of evidence and providing support during court proceedings when needed.

Family liaison officers may also assist families and witnesses by providing referral information and advice for external counselling and support agencies who can assist with your grief and loss during this difficult time.

Victorian Systemic Review of Family Violence Deaths

The Victorian Systemic Review of Family Violence Deaths (VSRFVD) is a unit within the Coroners Court of Victoria that is headed by the State Coroner of Victoria. The VSRFVD commenced at the Court in 2009. The VSRFVD is a multi-disciplinary team operating across the many areas of the court, comprising case investigators, lawyers, court registrars, family liaison officers and data specialists.

Under the Coroners Act 2008 (Vic) the functions of the VSRFVD are to:

  • examine deaths suspected to have resulted from family violence
  • identify risks and contributory factors associated with deaths resulting from family violence
  • identify trends and patterns in deaths resulting from family violence
  • identify trends and patterns in responses to family violence, and
  • provide coroners with information obtained through the exercise of the above functions.

Other supporting services

Police Coronial Support Unit

The Police Coronial Support Unit (PCSU) is staffed by members of Victoria Police who assist coroners with their investigations into deaths and fires.
The PCSU can attend scenes at the request of the coroner, provides coronial briefs of evidence for the coroner and supports Victoria Police members who are investigating matters on behalf of a coroner.

PCSU staff attend court to assist coroners at inquests and can also help families with the inquest process if required.

In court, PCSU staff are referred to as the coroner's assistant.

Victorian Institute of Forensic Medicine

The Victorian Institute of Forensic Medicine (VIFM) is co-located with the Coroners Court of Victoria at the State Coronial Services Centre at 65 Kavanagh Street, Southbank.
VIFM provides a ‘Medico-Legal Death Investigation’ service involving a team of consultant medical specialists and forensic scientists who assist with death investigations in Victoria and provide expert opinions in the fields of forensic pathology, clinical forensic medicine and forensic science both nationally and internationally.

VIFM is responsible for managing any medical scientific examinations that may need to be undertaken to help a coroner to identify the person who died and, if possible, their medical cause of the death. They also provide important health service follow-ups in circumstances where the medical investigation uncovers information that may have implications for other living relatives.

VIFM staff are also responsible for operating the Coronial Admissions and Enquiries office and the Donor Tissue Bank of Victoria.

More information can be obtained by visiting Victorian Institute of Forensic Medicine website.

Coronial Admissions and Enquiries

The Coronial Admissions and Enquiries (CA&E) is a 24-hour office that coordinates the initial phase of the coroner’s investigation including receiving reports of deaths and admitting people into the care of the coronial jurisdiction.

The CA&E also begins the initial process of requesting information that the coroner may need, such as medical records, to help in their investigation. Importantly, CA&E staff also manage the coordination of any medical scientific and forensic investigations to help the coroner establish the identify of the person who died and the medical cause of their death, if possible.

The medical scientific and forensic examinations are conducted by pathologists from the Victorian Institute of Forensic Medicine (VIFIM) who provide medical and scientific expertise to coroners to assist with the medical aspects of their investigations.

Staff from the CA&E can assist with information regarding:

  • viewings
  • the identification process
  • any medical examinations that may be required including the preliminary examination and/or an autopsy
  • the release of the person for the funeral
  • any questions families may have in relation to the initial stages of the coroner’s investigation
  • referral to external counselling and support services.
Last updated on 28 Feb 2023