Coronial jurisdiction in focus: prevention, power and process

The role, powers and functions of a coroner are fundamentally directed toward prevention. More than an aspirational focus, this is embedded in the statutory scheme.

This article considers how the coroner's functions operate in practice, the role of natural justice, and what interested parties should expect when engaging with the process.

Statutory scheme

In Victoria, the Coroners Act 2008 (Vic) (Act) establishes an independent jurisdiction to investigate deaths and fires, with the aim of reducing preventable harm. The statutory purpose is expressly framed around public health and safety, prevention, and the administration of justice.

The jurisdiction is inquisitorial rather than adversarial, but it remains anchored in procedural fairness.

While coronial proceedings are not designed to determine civil liability or criminal guilt, they frequently examine the conduct of institutions, professionals and individuals in a way that carries real consequences. The greater the public interest in an inquest, and the stronger its preventative focus, the more important it is to keep natural justice, procedural fairness and the limits of coronial power firmly in focus.

The players

A coronial investigation involves several participants, each approaching the process from a different perspective shaped by their role and interests. These include the coroner, who directs the inquiry and determines its scope; counsel assisting, who identifies issues and leads evidence; and the coronial investigator, who gathers and synthesises the factual material.

Central to the process are also the family (or senior next of kin), as well as interested parties, witnesses and often, public agencies and professional bodies.

Those competing perspectives can shape both the scope and direction of the investigation.

Counsel assisting

The Act permits a coroner to appoint a coroner’s assistant, including an Australian lawyer, the Director of Public Prosecutions or another person.

• The Court’s practice direction¹ makes clear that counsel assisting retains professional independence but takes instructions directly from the coroner and acts under the coroner’s direction. Counsel assisting does not represent the family or an institution, nor are they an independent advocate in the ordinary sense.
• In practice, effective counsel assisting builds and presents a tested evidentiary record. They do so without favouring one interested party over another. That balance is critical. It enables the coroner to discharge the statutory task while maintaining procedural fairness.
• Where a family is unrepresented, counsel assisting may help the family ask questions of witnesses at an inquest and raise any issues they wish the coroner to consider, where appropriate and while maintaining independence.

Coronial investigator

The Act provides for police assistance and empowers the coroner to direct a coronial investigator.

• The investigator takes instructions from, and acts subject to, the coroner’s direction.
• The role is central to factual reconstruction with many investigations often dependent on extensive documentary review, forensic analysis and witness evidence.

Interested parties

A person or entity may apply for leave to appear as an interested party.

• If granted such status, access may be given to relevant documents and be involved in an inquest including asking questions of witnesses and making submissions about witnesses and evidence. While the coroner ultimately determines scope and the calling of evidence, those decisions are frequently shaped by submissions and assistance of interested parties in the development of issues prior to inquest.
• The testing of evidence relies heavily on the participation of interested parties particularly in an inquisitorial jurisdiction where there is no identifiable "winner" or "loser".
• Interested parties should remain focused on advancing the forensic task, whilst remaining mindful of the inquisitorial nature of the process.

Powers of the coroner

Coroners exercise broad investigative powers.

• They may investigate deaths that fall within the statutory definition of a reportable death, and in some cases are required to investigate and hold an inquest. The Act also provides powers concerning control of the body, preliminary examinations, identification directions, autopsies, obtaining information, entry and search, the production of documents and prepared statements, and the holding of inquests. At an inquest, the coroner has procedural control and statutory authority to determine the scope and conduct of the hearing.
• However, those powers are not unfettered. They are directed to the statutory task of identification of the deceased, the cause of death, and the circumstances in which the death occurred.
• The coroner may also comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice. The jurisdiction therefore extends beyond analysis of medical cause-of-death and often into broader systemic examination, but only within the boundaries set by the Act.

The jurisdicton in practice

For organisations involved in a coronial process, several practical considerations consistently arise.

• Early preparation is key - this includes identifying and preserving documents, understanding likely areas of scrutiny, preparing witnesses for an inquisitorial setting and assessing at an early stage whether privilege, confidentiality, suppression or self-incrimination issues may arise.
• Considering concessions or admissions - the timing and extent of concessions can materially shape the course of an investigation. In some cases, they may narrow the issues or avoid the need for an inquest altogether.
• Conflicts - any potential risk as between an organisation and an employee should be identified and considered early and revisited as evidence develops.
• Self-incrimination - section 57 of the Act provides a mechanism for witnesses to object to giving evidence at inquest on the basis of self-incrimination. A coroner can nonetheless compel a witness to give evidence despite an objection made under section 57 if required in the interests of justice. This is a critical consideration when preparing for inquest². Outside of an inquest, section 50 of the Act provides a mechanism for a person to refuse to comply with a formal request to provide information to a coroner on the same basis.
• Adverse findings - where a coroner is minded to make an adverse finding, affected parties will generally be given an opportunity to respond. This is a key aspect of procedural fairness and should be approached with care.

After the findings

Powers of referral

• Under section 72 of the Act, a coroner may report to the Attorney-General and may make recommendations to ministers, public statutory authorities or entities on matters connected with the death or fire, including public health and safety and the administration of justice.
• Public authorities must respond within three months, outlining what action has been or will be taken. Those responses are published. Ministers are not required to respond to recommendations but will often do so in practice.
• Section 49 of the Act requires the principal registrar to notify the Director of Public Prosecutions if the coroner believes an indictable offence may have been committed in connection with the death.
• Coroners also regularly make referrals to regulators and other integrity and oversight bodies.

No liability in findings

Coronial findings have important limits.

• Section 69 prohibits a coroner from including in a finding or comment any statement that a person is, or may be, guilty of an offence. Even where findings are strongly critical, they do not themselves constitute a judgment in negligence, breach of duty, misconduct or criminal guilt.
• However, in practical terms, findings can have significant consequences. They often inform regulatory action, internal disciplinary processes, insurance responses and subsequent litigation.

Civil claims

The interface between coronial proceedings and civil claims is often unavoidable.

• In many contexts, the same facts may later appear in negligence proceedings.
• Coronial material can be influential. It provides a detailed factual record, but it is generated within a different procedural framework and for a different statutory purpose. The weight to be placed on that material in subsequent litigation requires careful consideration.

Use of evidence and findings

On a practical level:

• most coronial investigations are finalised by way of a written finding which is provided only to the parties to the proceeding. However, where an inquest has been held or recommendations are made, the finding will typically be published on the Court’s website. Findings may also be published in other circumstances, including where required by the statutory framework or where publication is considered necessary in the interests of public health and safety;
• responses to recommendations are also public;
• statutory safeguards exist, including suppression and non-publication powers where necessary to protect a fair trial or the public interest; and
• section 115 of the Act governs access to coronial material. Often strict release conditions will be ordered as per the Court's standard form. This prevents distribution and publication of coronial documents and allows limited internal use to discuss documents within a health service or a family unit.

Key takeaways

For anyone participating in a coronial investigation, this article highlights:

• the coronial process should be approached as a specialist jurisdiction with its own purpose, risks and opportunities and specialist advice should be sought;
• the jurisdiction should not be approached as though it were pre-litigation discovery, or a wide public inquiry without jurisdictional limits; and
• the most effective participation is directed to assisting the coroner to reach accurate, prevention-focused conclusions, while ensuring that the path towards those conclusions is lawful, balanced and just.

Footnote:

¹ Practice Direction 3 of 2014 - Communications with the Court
² See recent example the ruling of Coroner Dimitra Dubrow dated 28 January 2026 on application to be excused from giving evidence in the Daylesford inquest. See also example ruling of State Coroner Judge Cain dated 22 December 2022 on application for witnesses to be excused from giving evidence in the St Basil's inquest.