Death investigation process
A coroner’s investigation involves a few organisations who work together to make the investigation as timely as possible.
Deaths a coroner may investigate include:
- unexpected, unnatural or violent deaths (including homicides and suicides)
- when the identity is not known
- when the cause of death is not known
- when a person who was in care or custody dies.
Other professions are also obliged to report certain deaths, such as prison officers or children’s services who have care or custody of a person or child.
While each investigation is different, there are general stages for most reported deaths.
Receiving a report of a death
The Coronial Admissions and Enquiries department at the Victorian Institute of Forensic Medicine (VIFM) coordinates the initial phase of the coroner’s investigation.
- receiving the report from the police, a doctor/hospital or another reporting body
- admitting the deceased person into the care of the court
- contacting the senior next of kin to advise them about the coronial process, and obtain more information about the deceased and the family’s wishes with respect to the deceased’s post-mortem examination
- requesting medical information to assist the Forensic Pathologist with the preliminary examination of the deceased.
A coroner is on duty at all times and may attend the scene of the death when it is safe and appropriate to do so.
Immediately after a death, Victoria Police will start gathering information to form an initial report for the coroner.
Victorian Institute of Forensic Medicine
A forensic pathologist will undertake an examination of the deceased, which includes:
- radiological scans, such as full body CT scans
- a visual examination or post-mortem autopsy
- the taking of bodily fluid such as blood, urine, saliva and mucus
- the taking of samples from the surface of the body, including swabs from wounds and inner cheek, hair samples and samples from under fingernails and from the skin for testing.
The coroner may order further investigations to help establish identity and cause of death.
The forensic pathologist will provide a Medical Examination Report to the coroner. This report may take up to several months, but sometimes longer.
Determining the course of an investigation
Based on all the information and evidence gathered, the coroner will decide if the death requires further investigation, or if the death was due to natural causes.
As part of any investigation, the coroner may:
- obtain information and documents from various people and organisations
- request expert reports and opinions
- determine if an inquest is required
- request Victoria Police to compile a coronial brief
- conduct research and consider potential recommendations.
We will be in touch with the senior next of kin throughout the investigation process.
The coroner will make a finding at the end of every investigation, sometimes with recommendations. These findings are published on our website, unless otherwise ordered by a coroner.
A finding is a formal document prepared by a coroner following an investigation into a death or fire.
A finding made following an inquest is often delivered in court by the coroner. However, it can also be delivered outside of court, through email, or the post. This is called an inquest finding.
Finding without inquest
A finding without inquest is where the coroner makes a finding based on the material available without a public hearing in court.
Most coronial investigations are finalised without inquests. Only findings without inquests that contain recommendations made by a coroner are published on our website, unless a coroner orders otherwise.
If a finding without inquest is undertaken, the senior next of kin will be informed.
Investigations vary in duration
Every death and fire investigation requires an individual approach and their duration can vary.
The investigation’s duration depends on:
- the complexity of the matter
- if an inquest will be held
- if there are other investigations that need to be undertaken by other authorities first
- if the matter is before another court – for example, someone has been charged with criminal offences.
The flow chart below outlines the various processes and stages of a coroner's investigation into a death. This flowchart is also available to download.
The process for investigating fires differs from the process for investigating a death.