Role of a Coroner

The purpose of inquests is to enable coroners to carry out the functions of the coronial system in Victoria according to the Coroners Act 2008 (Vic) by conducting independent investigations into reportable deaths and make findings and recommendations that contribute to:

• A reduction in the number of reportable deaths
• The promotion of public health and safety, and
• The administration of justice.

At the conclusion of an inquest, a coroner must, if possible, find:

• The identity of the deceased
• The medical cause of death, and
• The circumstances in which the death occurred (except in exceptional circumstances not relevant to this Inquest).

Coroners may also comment on any matter connected with a death being investigated, including matters relating to public health and safety or the administration of justice.

Coroners are not permitted to make findings, or any comments or statements, about any person being guilty of an offence.

Coroners may also make recommendations to any entity on any matter connected to the death(s) being investigated, including matters relating to public health and safety or the administration of justice.