The coronial inquiry and hearing

When a coroner opens a coronial inquiry the purpose is to establish the cause and circumstances of death and find out what could be done to reduce the chances of future deaths in similar circumstances.

Coroners don’t hold inquiries into all deaths reported to them. After a natural death they may make a finding without having to open an inquiry. An inquiry usually begins only after any criminal prosecution, and any appeal, has been completed. If the coroner is satisfied that the court has adequately established the cause and circumstances of death the inquiry might not go ahead.

If the coroner does proceed with an inquiry to investigate and determine the cause and circumstances of the person’s death, they will gather a lot of evidence from the police and other agencies.  An inquiry can take a long time, even years in some cases and often there is a wait to receive the outcome of investigations being conducted by other agencies.

Once the coroner has gathered all the evidence required, a hearing is held. A hearing involves the coroner looking carefully at all the evidence collected during the inquiry and determining the cause and circumstances of the death There are two ways that a coroner can hold a hearing. It can be held ‘on the papers’ or at an ‘inquest’. The differences between these are explained below.

A hearing on the papers
A hearing on the papers is held privately in the coroner’s office (chambers). It is the most common way a coroner completes his/her findings. The coroner decides on the cause of death by using all the paper evidence available; the post mortem report, statements from family, whānau, and other witnesses, and reports from police and other agencies. It may take the coroner several weeks to write the finding. This hearing isn’t held in public and family, whānau, witnesses, or other interested parties cannot attend.

An inquest
However, if there are complicated issues relating to the death or significant speculation or public interest in the case, an inquest is usually ordered by a coroner. An inquest is a public hearing held in a public coroner’s court or other formal venue.

If an inquest hasn’t been ordered, families, whānau, and other interested parties can still request that the coroner holds one and explain the reasons why. The final decision on whether or not an inquest will be held is made by the coroner. Contact the coronial case manager if you want to talk to the coroner.

An inquest will be held openly in the Coroner’s Court and is usually a public hearing and members of family, whānau, witnesses, other interested parties, and the public can attend. The family or whānau of the person who has died will be told by their coronial case manager when and where it is. There are some sensitive circumstances when the coroner is able to use their discretion to keep people out of all, or part, of the inquest.

During the inquest, the coroner will decide which things they want to find out more about and who they would like to hear from. Evidence can be provided from a wide range of people, including family, whānau, friends, others who knew the person, and any witnesses. The coroner and anyone in the court can question those giving evidence if the coroner allows this. This means you and other members of the immediate family or whānau can ask questions, or you may like to have a lawyer to ask those questions for you.

If you are asked to give evidence at the inquest
This is to help the coroner better understand what happened. Your coronial case manager will get in touch to tell you when you will need to be at the inquest and where it is. They will also talk with you about what to expect.

You can bring support people with you
Family, whānau, and friends are welcome to come to the inquest with you. Your Victim Support Worker can also be with you. Contact them directly or call 0800 842 846 to arrange a support person to be there alongside you.

You can choose not to attend the inquest
There can be a lot of sensitive details openly talked about, which can be distressing. Your Police Victim Liaison Officer will talk with you about the hearing and what to expect. You can ask them any questions and have support people with you, including your Victim Support Worker, if you are a witness or just attending.

Inquests are usually open to the public, including the media
Everyone attending the inquest will hear everything that’s said, unless the coroner does not allow this. The coroner can decide to keep people out of all or part of the inquest. The media can publish the details of an inquest except in the case of a suicide, or if the coroner limits what information can be published.

Read about how the coroner makes their inquiry and inquest findings known here. 

For more about how an inquest is run, see When Someone Dies Suddenly. A guide to coronial services in New Zealand.

Other useful websites and information

More about the coronial process

Coroners’ investigations and post mortems by Community Law


Your rights as a victim