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- What to expect during an inquiry
Overview
If the coroner opens an inquiry, they will look more closely at the death of your loved one to understand what happened.
A coronial inquiry
A coronial inquiry is when the coroner investigates a death to find out, as far as possible:
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who died
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where they died
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when they died
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how they died
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why they died.
The coroner’s inquiry does not determine whether someone is guilty of a crime or legally responsible for a death.
The coroner may also make comments or recommendations to help prevent similar deaths from happening in Aotearoa New Zealand in the future.
When an inquiry is opened
A coroner’s inquiry can be opened soon after the death, but the decision can sometimes take longer depending on the circumstances.
Not every death referred to the coroner needs an inquiry. The coroner may decide an inquiry is not needed, such as, if the death was from natural causes. Then the family and whānau will receive a notice from the coroner stating the cause of death, and the coronial process is finished for family and whānau.
Find out when a coroner may open an inquiry and what happens during one:
Who can help
Coroners are supported by a case manager who works closely with them and helps keep family and whānau informed about what is happening.
You will receive a letter with their contact details, and they will be your main contact.
The case manager can help explain the coronial process and will keep you updated when there is information to share.
If you change address, phone number or email let the case manager know.
When an inquiry is on hold
Sometimes an inquiry may be put on hold while another process is being completed. This can happen if another agency is investigating the death or if there is a prosecution.
The coroner may wait for the results of those processes before deciding whether the inquiry should continue. Sometimes the inquiry does not need to be continued as the other investigation has established all necessary matters.
Some examples of when this can happen are below.
New Zealand Police
Police may do their own investigation related to the death of your loved one. For example, if Police are investigating a suspected homicide, serious road crash, or another death where criminal charges may be considered.
WorkSafe
WorkSafe may have started an investigation into the death of your loved one. This can be because the death happened at a workplace and WorkSafe is investigating whether workplace health and safety laws were followed.
How we investigate | WorkSafe(external link)
The Health and Disability Commissioner
The Health and Disability Commissioner may have started an investigation into the death of your loved one. For example, if there are concerns about the healthcare, treatment, or support a person received before they died.
Formal investigations | Health & Disability Commissioner(external link)
What happens during an inquiry
During the inquiry, the coroner gathers evidence and statements to help establish the facts of how the person died. This information can come from police, employers, colleagues, friends, family, whānau, witnesses, medical professionals and other agencies such as, Worksafe and the Health and Disability Commission.
Inquiries can vary in length and can take several years where a complex inquiry is required. The time your loved one’s inquiry takes will depend on the circumstances of how they died, the evidence the coroner needs to gather and whether the coroner is waiting for a prosecution or any other investigation to finish.
A hearing happens towards the end of an inquiry. This is when the coroner looks at all the evidence that has been gathered and decides on the facts of the death. This may be by:
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holding an inquest, which is a public court hearing
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holding a hearing on the papers (also known as a chambers hearing) where the coroners consider all the evidence they have gathered in their office (chambers).
Hearing on the papers
A hearing on the papers is when the coroner makes a written findings without holding a public hearing.
This is the most common way for a coroner to complete their findings.
Family, whānau, witnesses and other interested parties do not attend a hearing on the papers. The coroner makes the finding after reading and considering the evidence that has been gathered.
It may take weeks or months for the coroner to release the written finding.
It may take longer if the coroner needs to give people or organisations time to respond to proposed recommendations or comments that may affect them.
Inquest
An inquest is a public hearing.
The coroner may hold an inquest if they need to hear from witnesses in person. Inquests are less common than hearings on the papers. They are usually held when a case is complex, evidence needs to be heard in person, or there is a lot of public interest.
Family, whānau and other interested parties can ask the coroner to hold an inquest. The coroner will take this into account.
Interested parties can also ask to give evidence or question witnesses.
If an inquest is held, it may be attended by:
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family and whānau
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witnesses
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interested parties
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members of the public
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accredited media.
An inquest is usually held in a courtroom. The coroner may approve another place, such as a conference room or marae.
Family and whānau, or their lawyer if they have one, can question witnesses. The coroner can also ask questions.
The coroner may have a lawyer helping them with the inquiry. This lawyer is called 'Counsel Assisting the Coroner'.
You do not need to have a lawyer at an inquest, but you can choose to have one. You can also have support people with you, such as family, whānau or friends.
Access to information during the inquiry
During the inquiry, family and whānau may be entitled to a copy of:
- the provisional post-mortem report
- the final post-mortem report.
You can talk to the case manager to help you get a copy of these reports.
The coroner decides who can access other information on the case file while the inquiry is still happening. Some documents may not be released during the inquiry because they are part of the evidence the coroner is considering.
If you are worried about information being made public
If you are worried about information being made public, you should tell the coroner before the case is closed. You can contact the case manager to tell the coroner on your behalf.
Coroners Court proceedings are usually public. The family and whānau of the person who died, or another interested party, may apply to the coroner for a non-publication order.
A non-publication order can stop specific details or evidence from being made public. If you're applying for a non-publication order, you'll need to have strong grounds for applying as these orders are issued in limited circumstances.
If you would like to understand more about non-publication orders, including when they may be available and how to apply, visit: