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Role of the Coroner When is a death reported to the Coroner? How is a death reported to the Coroner? What will the Coroner do? What happens at an inquest? How is the death registered after an inquest? What documents are then issued, and who to? Inquiry Q: Why does a coroner open an inquiry? Q: How involved can the family be in the inquiry? Q: How long will an inquiry take? Q: What is the difference between an inquest and an inquiry? Inquest Q: Why is an inquest held? Q: Where is an inquest held? Q: How long will an inquest take? Q: What happens at the inquest? Q: Does an inquest always follow a post-mortem? Q: Will there be a jury at the inquest? Q: Must a witness attend court? Q: Who decides which witnesses to call? Q: Do I need a lawyer for the inquest? Q: Can I question a witness at the inquest? Q: Can I get copy of the findings and recommendations? Q: What information of the case will be public? Q: Will the inquest decide who is to blame? Q: Can the funeral be held before the inquest is held? Post-Mortem Q: What is a post-mortem? Q: Why is a post-mortem done? Q: How long will a post-mortem take? Q: Can I object to a post-mortem? Q: Can I get a copy of the post-mortem report? Q: Will they keep any body parts? Funeral Q: Do I have to use the funeral director who takes the deceased to the mortuary? Q: How do I choose a funeral director? Q: Who registers the death? Q: How do I get a copy of the death certificate? Q: When will the deceased be released so we can hold a funeral? Q: Are there restrictions on where we can bury the deceased? Q: What is needed before the deceased can be cremated? Q: Can the funeral be held before an inquest is held? General Q: Why do the Police become involved in a death? Q: What happens if somebody has been charged with causing the death? Q: Where will the deceased be held? Q: How do I retrieve personal belongings that were with the deceased at the time of death? Q: Who has to identify the deceased? Q: What about our cultural and spiritual beliefs? Q: Are all deaths occurring in hospital reported to a coroner? Q: When is a medical certificate as to cause of death issued? Q: How can I find out what is happening? Q: Can future deaths be prevented? Who is the deceased? This can be answered by looking at identification found on the deceased or through verification by family members or friends. When identification of an individual is unable to be determined, DNA can be tested to determine identity. Dental records can also be compared to the deceased when possible. How did the deceased die? This question can be answered by determining the circumstances of death. This is different than why a person died in that it does not provide the medical explanation for death. For example, an accident may be how a person died, but head trauma would explain the reason why death occurred. Where was the deceased found? This question can be answered by the person who found the deceased or by officers called to the scene. It is important to know the location and position of the body as well as the condition of the surrounding area. Where did the deceased die? While the answer to this question will typically be the same as the answer to the above question, a difference will exist in cases where the deceased has been moved. It is important to know the location of death in order to look for evidence of how, why, or when death occurred. When did death occur? This can be answered by determining when the deceased was last seen and how much time has passed since that time. This provides a frame within which death must have occurred. Determining the actual time of death, however, is very difficult to do. As a result, while an approximate time of death can be determined by asking the previous questions, the time of death as recorded by the Coroner's Office is the time at which death is confirmed upon responding to a call. Why did the deceased die? This question asks why a person died in a given situation. As explained in the question of how above, the answer to why a person died will be the particular medical reason for death. In an accident, for example, head trauma would explain the reason why death occurred. In other words, the question of why can be answered by determining the particular cause of death. Determining the medical history of the deceased can also provide insight into why a person died. It is also important to know what medications were in the possession of the deceased at the time of death. Why a person died can ultimately be determined through autopsy and toxicology tests. It is possible, however, that why a person died cannot be determined by autopsy or toxicology results. What is the manner of death? While the Coroner's Office does not investigate legal matters concerning death, the manner of death may be apparent through determining why a person has died. Based on autopsy or toxicology findings, it may be determined that a person died by homicide, suicide, accidental death, natural death, or an undetermined manner of death. Q: Why is a death reported to the coroner? Anyone who finds a body in New Zealand must report the death to the Police, who must then establish whether the death needs to be reported to a coroner. The law requires certain deaths to be reported to the coroner which include: without known cause, suicide, unnatural or violent; where a doctor cannot give a certificate as to cause of death; that occurred during, or as a result of, a medical, surgical or dental procedure; that occurred while, or as a result of, a woman giving birth; and while the deceased was in official custody or care. Q: What does a coroner do? The coroner will carry out an inquisitorial process to ensure that the identity of the deceased and the cause of death are known, to establish when and where the person died and to understand the causes and circumstances of the death. At the end of this process the coroner may make recommendations or comments that, if drawn to public attention, may reduce the chances of the occurrence of deaths in similar circumstances. Inquiry Q: Why does a coroner open an inquiry? The coroner will open an inquiry to establish identity of the deceased, the time and place of death and the causes and circumstances of the death. From this, the coroner may then make recommendations that, if drawn to public attention may reduce the chances of deaths occurring in similar circumstances. Q: How involved can the family be in the inquiry? The Coronial Services of New Zealand want to ensure that the immediate family is involved in the process as much as they wish, or need, to be. There will be certain matters that the family needs to be advised of, and perhaps information will be requested from the family during the process of investigating the death. Q: How long will an inquiry take? Each and every death is different, and the coroner will want to ensure that the death is fully investigated in order to establish the causes and circumstances of death. The coroner may commission an examination or investigation of a person or corporate, medical or otherwise. These investigations may take time. If any other agency, including the Police, is undertaking an investigation, then the coroner may postpone the Inquiry until the other investigation is completed. This could include a criminal investigation. There is no set timeframe. Q: What is the difference between an inquest and an inquiry? An inquiry is opened to establish identity of the deceased, the time and place of death and the causes and circumstances of the death. In order to review the evidence and hear witness statements, the coroner will hold an inquest, which is a Judicial hearing convened by a coroner and can be more informal than some court hearings. Inquest Q: Why is an inquest held? The inquest is held so the coroner can review all the evidence relating to the death and discover what lessons can be learnt from it. The coroner will hear evidence from anyone who has information relating to the death. The inquest also enables the coroner to make recommendations or comments on the avoidance of circumstances similar to those in which the death occurred, or to comment on how other people should act in such circumstances, so as to reduce the chances of other similar deaths occurring. Q: Where is an inquest held? The inquest is held either in the District Court or at another chosen venue. The Coronial Services of New Zealand will advise you of the time, date and location of the inquest once it has been set. Q: How long will an inquest take? The duration of an inquest will depend on the complexity of the case and how many witnesses are called to give evidence. Most inquests are completed within a day, sometimes in less than an hour. The more complex cases could last for up to two weeks or more. Q: What happens at the inquest? The coroner conducts the inquest, witnesses and experts may be called upon to give evidence or witness statements may be read, and the pathologist's report, papers and any other findings may be presented. The immediate family can, either personally or through legal counsel, question witnesses. The coroner may make comments on the circumstances surrounding the death and is able to make recommendations, for example, about faulty products or unsafe work practices. If the coroner intends to make any criticism of the deceased or any other person or body corporate, the coroner will inform the family or people concerned prior to the release of the findings. This is to ensure they have an opportunity to be heard in relation to the matter, either personally or through legal counsel. Q: Does an inquest always follow a post-mortem? No. Once a post-mortem has been conducted, if the coroner can ascertain cause and circumstance of death and does not have any recommendations or comments on the avoidance of circumstances similar to those in which the death occurred, then no inquest will be held. Q: Will there be a jury at the inquest? No, there is no jury at a coroner's inquest in New Zealand. Q: Must a witness attend court? If a witness is called to give evidence at an inquest, they are required by law to attend. A witness who gives evidence at an inquest must do so orally on oath or affirmation and may be cross-examined by: 1. the coroner; 2. the immediate family (either personally or by legal representation); or 3. any other person or body corporate notified of the date, time and place of the inquest under section 81(1)(b) of the Coroners Act 2006. A witness at an inquest may give any evidence by tendering a previously prepared written statement and confirming it on oath or affirmation if the coroner is satisfied that it does not need to be given orally and no objection is raised by anyone attending the inquest. Q: Who decides which witnesses to call? The coroner will decide which witnesses need to attend the inquest following discussions with the New Zealand Police and other parties. Q: Do I need a lawyer for the inquest? You do not need to have a lawyer to take part in the inquest, but you may feel more comfortable by having a lawyer to put questions to any witnesses rather than ask the questions yourself. The choice is up to the individual family. Q: Can I question a witness at the inquest? The family may put questions to any witness that takes part in the inquest. You may, however, feel more comfortable by having a lawyer represent you. Q: Can I get copy of the findings and recommendations? After hearing all the evidence, the coroner will announce his findings and once the inquiry is closed will publish his recommendations. A copy of this will be made available to the family. Q: What information of the case will be public? An inquest is usually open to the public. In a very small number of cases the coroner may decide to hold a closed inquest. All details discussed at an inquest will be heard by anyone who attends the inquest, which may include the media. The media may publish any information that they hear EXCEPT in relation to a suicide where there are restrictions imposed by law. The law restricts details relating to a suicide death from being made public without a coroner's permission. Prior to a coroner's findings, only the name and age of the deceased may be made public. After a coroner's findings (if any) have been released, only the name, address and occupation of the person concerned and the fact that the coroner found the death to be a suicide can be made public without a coroner's permission. Any person making public any other information without a coroner's permission is committing an offence and can be fined in accordance with section 139(a) of the Coroners Act 2006. Q: Will the inquest decide who is to blame? The coroner's inquest is an inquisitorial process to discover what happened rather than to hold a trial to apportion blame. The recommendations made by the coroner, if any, may draw public attention to the circumstances surrounding the death that may prevent any future death in similar circumstances. Q: Can the funeral be held before the inquest is held? Once the coroner has authorised the release of the deceased, the family may hold the funeral. You should contact a funeral director as soon as possible after you have been advised about the death so that arrangements for the funeral can be made. Once the funeral home collects the deceased, your arrangements are already in hand. You do not need to wait for the inquest before you hold the burial or cremation. Post-Mortem Q: What is a post-mortem? A post-mortem is sometimes called an autopsy. It is a thorough internal and external medical examination by a specialist medical practitioner, known as a pathologist, and is usually conducted at a hospital mortuary. Not all hospitals have a mortuary where a post-mortem can be conducted, so the deceased may be transported to a larger town nearby. The family will not incur any costs for transporting the deceased to the mortuary and back to the original location for the purposes of undertaking a post-mortem. Q: Why is a post-mortem done? There are many factors that influence the coroner when deciding whether a post-mortem should be performed. The most important of these decisions are: * the need for more details to establish the cause of death; * whether there are any suspicious circumstances surrounding the death; and * the desirability to minimise offence to the family due to their cultural or spiritual beliefs. If the coroner decides to direct a post-mortem, the immediate family or their representative will be notified immediately and, in most cases, given an opportunity to advise the coroner of any objections. Q: How long will a post-mortem take? Every effort is made to conduct a post-mortem quickly so that the coroner can authorise the release of the deceased. This usually means examination on the next working day with release of the deceased that same day. Coroners can authorise a 'forthwith' examination for certain cases, or on public holidays or weekends. Sometimes there is a requirement for a more detailed or specialist analysis to help establish the cause of death, particularly in suspicious deaths, and this may result in a delay of one to three days before release. Although many ancillary tests may be made later on minute samples taken even in routine examinations, this does not mean the deceased cannot be released. Q: Can I object to a post-mortem? The coroner is required by law to notify the immediate family or the family representative of the decision to direct a post-mortem. The immediate family has a right to object to the post-mortem EXCEPT: * where the death is a result of conduct that constitutes a criminal offence; or * where any other New Zealand or International law requires a post-mortem to be carried out; or * if the coroner has directed a post-mortem be performed immediately because any delay would or may limit the pathologist's ability to determine cause of death. Any objection must be lodged with the coroner within 24 hours of receiving notification of the coroner's decision. If the family raises an objection, the coroner must review the decision on whether to continue with a post-mortem. If the coroner is satisfied that a post-mortem is still necessary, the immediate family have 48 hours to lodge an objection with the High Court under section 34(3) of the Coroners Act 2006. The objection will be dealt with by the High Court as a matter of priority and urgency and allocated a hearing date on the next working day. To lodge an appeal with the High Court, please contact your local Coronial Services Co-ordinator who will advise you who to contact to proceed with an objection in the High Court. Q: Can I get a copy of the post-mortem report? The immediate family can request a copy of the post-mortem report providing release of the report will not prejudice any ongoing Police investigation. The Coronial Services of New Zealand will advise the family when the report is available. A copy will be provided to the family free of charge. Due to the possible graphic content and the complex medical language in the report, it is recommended that the report be released to the family doctor who can discuss it with you. Q: Will they keep any body parts? There may be a need to remove organs or body samples during the post-mortem. Minute samples that are taken for analysis are often used up during the testing process. In some cases, the pathologist may request the retention of these organs or body samples for further investigation. Before releasing the deceased to the family, the coroner will advise the family of any request from the pathologist to retain any parts or samples. The family has the right to request any body parts and samples be returned to them, where safe to do so, once the pathologist has finished any further analysis. Funeral Q: Do I have to use the funeral director who takes the deceased to the mortuary? The duty funeral director who transports the deceased to the mortuary is under contract to the New Zealand Police. The family is not obliged to use the same funeral director for any arrangements they wish to make for the funeral. Q: How do I choose a funeral director? Funeral directors can be found by looking in the telephone book, the Yellow Pages or a local newspaper. It is recommended that you contact a funeral director as soon as possible after the death. Once you have engaged a funeral director, they will be able to guide you through the coroner's process and seek release of the deceased. Q: Who registers the death? Notification of the death will be sent to Births, Deaths and Marriages by the Coronial Services of New Zealand once the coroner authorises the release of the deceased. If an inquiry is to be held, this initial notification will give an interim cause of death, which will state 'Subject to Coroner's Findings'. In these circumstances, the final cause of death will not be confirmed until the coroner announces his findings at the end of an inquest. Final notification of death will be forwarded to Births, Deaths and Marriages by the Coronial Services of New Zealand. Q: How do I get a copy of the death certificate? Once a death is notified to Births, Deaths and Marriages, it is possible to request a death certificate. If an inquiry is to be held, this may only be an interim certificate, which states 'Subject to Coroner's Findings' in the cause or causes of death field. There is no fee payable to Births, Deaths and Marriages for notification of a death for registration, but a fee applies when you request a death certificate. Births, Deaths and Marriages will update the cause of death with the coroner's findings, and if an interim death certificate is returned then a replacement death certificate, including the full cause of death, will be available at no additional cost. Contact details for Births, Deaths and Marriages can be found in the Government section of the white pages or visit their website at www.dia.govt.nz Q: When will the deceased be released so we can hold a funeral? Each death is different and unique, so there is no set timetable as to when and how things will happen. Once the legal and medical requirements are complete the coroner will authorise the release of the deceased. Q: Are there restrictions on where we can bury the deceased? If the family has engaged a funeral director, they will be able to advise you of what is needed and may be able to help with the process. If the family is making their own arrangements, there is a booklet produced by the Department of Internal Affairs entitled "Before Burial or Cremation" which provides all the information you need. For more information visit www.dia.govt.nz Q: What is needed before the deceased can be cremated? If the family has engaged a funeral director, they will be able to advise you of what is needed and may be able to help with the process. If the family is making their own arrangements, there is a booklet produced by the Department of Internal Affairs entitled "Before Burial or Cremation" which provides all the information you need. For more information visit www.dia.govt.nz Q: Can the funeral be held before an inquest is held? Once the coroner has authorised the release of the deceased, the immediate family may proceed with any funeral arrangements they wish. General Q: Why do the Police become involved in a death? The reporting of a death to the Police does not necessarily mean that a crime has been committed. By law, anyone who finds a body in New Zealand must report the death to the Police, who then establish whether the death needs to be reported to a coroner. For most deaths, a doctor is able to sign a medical certificate stating cause of death. This is usually done if the deceased was a recent patient and the doctor can be certain of the cause of death. The Police must by law report the following deaths to a coroner: * without known cause, suicide, unnatural or violent; * where a doctor cannot give a certificate as to cause of death; * that occurred during, or as a result of, a medical, surgical or dental procedure; * that occurred while, or as a result of, a woman giving birth; and * while the deceased was in official custody or care. Q: What happens if somebody has been charged with causing the death? Where an individual has been charged with causing someone's death, e.g. by murder or manslaughter, the coroner may either: 1. postpone opening an inquiry; 2. open and adjourn an inquiry; or 3. adjourn an inquiry, pending the outcomes of any criminal charges. Before the inquiry is adjourned, the coroner will establish the identity of the deceased and the cause of death. The coroner will then register the death. The coroner may later open or resume an inquiry if satisfied that any charges against the person have been dropped or that to open or resume the inquiry would not prejudice the person charged, or thought likely to be charged, with a criminal offence relating to the death or its circumstances. In many cases, the coroner will wait until any trial is over. Q: Where will the deceased be held? The deceased will be in the care of the coroner until such time as the coroner authorises the release of the deceased. They will be taken to a place of safety (i.e. hospital mortuary or funeral home) until the coroner makes a decision if a post-mortem is required. Q: How do I retrieve personal belongings that were with the deceased at the time of death? Police or medical personnel may return personal items (i.e. jewellery, wallet or clothing) at the time of death. Alternatively, the Police or funeral director may return these items to the family in the following days. Some items may need to be retained for a forensic investigation or for any on-going Police inquiry, and will be returned to the family at a later date. Q: Who has to identify the deceased? Formal identification will need to be made of the deceased. Medical personnel may do this if present at the time of death or the deceased is known to them. Personal items/dental records/DNA may be used to assist in identification if needed. A witnessed statement will need to be signed by the person doing the identification. It is important that the identification is done as quickly as possible so next of kin can be advised of the death. Once next of kin are advised, details (name and age) may be released to the media. This will not be done until immediate next of kin have been advised. Q: What about our cultural and spiritual beliefs? Every effort will be made to recognise the spiritual and cultural beliefs surrounding the death of your loved one. The coroner will be aware during the decision making process of the need to minimise distress to the family who, by reason of these spiritual and cultural beliefs, find a post-mortem offensive and who require the deceased to be available to the family as soon as possible after death. Where circumstances and the coroner allow, the immediate family may be able to remain with, or within a reasonable distance of, the deceased while they are in the custody of the coroner. If the family so desire, and if authorised by the coroner, a doctor, nurse, funeral director or any other person may be able to attend a post-mortem as a representative of the family. Q: Are all deaths occurring in hospital reported to a coroner? No. For most deaths, a doctor is able to sign a medical certificate stating cause of death. This is usually done if the deceased was a recent patient and the doctor can be certain of the cause of death. Where the cause of death cannot be confirmed or the deceased's doctor is not available, by law the death must be reported to the Police, who then establish whether the death needs to be reported to a coroner. Under section 13(1)(c) and (d) of the Coroners Act 2006, the following deaths that occurred in hospital must always be reported to the coroner for investigation: 1. any death that occurred while the person concerned was undergoing a medical, surgical, dental or similar operation or procedure; 2. any death that appears to have been the result of an operation or procedure of that kind; 3. any death that appears to have been the result of medical, surgical dental or similar treatment received by that person; 4. any death that occurred while that person was affected by anaesthetic; 5. any death that appears to have been the result of the administration to that person of an anaesthetic or a medicine (as defined in section 3 of the Medicines Act 1981); or 6. any death that occurred while the woman concerned was giving birth, or that appears to have been a result of that woman being pregnant or giving birth. Q: When is a medical certificate as to cause of death issued? For most deaths, a doctor is able to sign a medical certificate stating cause of death. This is usually done if the deceased was a recent patient and the doctor can be certain of the cause of death. If the death has been referred to the coroner, notification of the death will be sent to Births, Deaths and Marriages by the Coronial Services of New Zealand once the coroner authorises the release of the deceased. If an inquiry is to be held, an interim cause of death will be notified which will state 'Subject to Coroner's Findings'. In these circumstances, the final cause of death will not be confirmed until the coroner announces his findings at the end of an inquest. Final notification of death will be forwarded to Births, Deaths and Marriages by the Coronial Services of New Zealand. Q: How can I find out what is happening? Each death is different and unique, so there is no set timetable as to when and how things will happen. The immediate family will be kept informed of progress as much as possible throughout any inquiry or inquest that may be opened by the Coronial Services of New Zealand. If you have any questions or concerns, please contact either the Coronial Services Co-ordinator who has been liaising with the family, or the Police Inquest Officer. Q: Can future deaths be prevented? Sometimes the coroners findings will show that something needs to be done to prevent deaths occurring in similar circumstances. The coroner can draw attention to this by making public his findings and they may write to someone in authority about the issue, for example the council or a government department. PRIMARY DUTIES AND RESPONSIBILITIES include the following. Directs activities of staff physicians, technicians, and investigators conducting inquests, performing autopsies, conducting pathological and toxicological analyses, and investigating circumstances of deaths to determine cause and fix responsibility for accidental, violent, or unexplained deaths. Conducts inquests, hearings, and inquiries. Confers with officials of public health and law enforcement agencies to co-ordinate inter-departmental activities. Co-ordinates activities for disposition of unclaimed corpse and personal effects of deceased. Directs activities of workers involved in preparing documents for permanent records. Assists relatives of deceased by providing information concerning circumstances of death. SUPERVISORY RESPONSIBILITIES Directly supervises Deputy Coroners and two to four full time employees in the Coroner's Office. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. |