State Coroner’s Court of NSW

The State Coroner is required under the Coroners Act 2009 (NSW to ensure that all deaths, suspected deaths, fires and explosions are properly investigated and, if required, ensure that an inquest is held.

The court is constituted by the State Coroner and Deputy State Coroners, who are Magistrates. All Local Court Magistrates in NSW are Coroners and may by assisted by an Assistant Coroner.

The court only has jurisdiction to investigate the circumstances of a death connected to the State of NSW. At the time of death the deceased must have been a NSW resident, in NSW or travelling to or from a place in NSW.

Explosions must have occurred in NSW.

Doctors, healthcare professionals, emergency service workers and police are obliged to report certain deaths to the Coroner. Doctors must not issue a death certificate and instead must refer a matter to the coroner in cases of:

unexpected death
violent or unnatural death
deaths resulting from an accident or injury
deaths occurring during or following a health related procedure
when a Medical Certificate of Cause of Death has not been signed and is not likely to be signed
persons who had not attended a doctor in the last six months
unidentified persons
deaths in custody
persons receiving care treatment and assistance in a mental health facility.

The jurisdiction is inquisitorial, not adversarial. The principal function is to find out what occurred and how it may be prevented from happening again. The inquest or inquiry and does not determine criminal or civil liability, though the coroner’s findings may be relevant to any subsequent proceedings.

A Coroner may suspend an inquest or inquiry and refer the matter to the Director of Public Prosecutions if he or she forms the view that an indictable offence has been committed in connection with the death.

The Coroner may make recommendations to governments and their agencies to improve health and safety and prevent future deaths. However, the Coroner does not have the power to enforce the recommendations as this is a matter for the relevant government Minister.

Magistrate Michael Barnes is the current State Coroner.

The State Coroner’s Court is located at 44 Parramatta Road, Forest Lodge NSW 2037, tel (02) 8584 7777.