When the Coroner is Called

A coroner’s job is to find out exactly where, when, how and why an unexpected or sudden death has happened. If the police find a death unexpected or suspicious, or if a medical professional cannot easily determine the cause of death, a coroner will be called.

Once the coroner has been called, the body cannot be buried or cremated until the coroner has issued release documents, at which time you or your chosen funeral director can pick up the body from the hospital mortuary. This process is very important to undertake to help prevent similar deaths of the same nature in the future. The more we know, the more we can act to prevent it.

What happens when a coroner is called?

Here is a brief timeline of what to expect when a coroner is called:

1. The police or medical professional in charge will call the coroner.
2. The coroner will call the family to let them know. Anyone in the immediate family of the person who has died (partner/spouse, children, parent, siblings, grandparents, grandchildren) has the right to be informed about what is happening throughout the coronial process.
3. The coroner will decide if a post-mortem (also known as an autopsy) is needed. A post-mortem is the examination of a body after death to determine the cause of death.
4. If a post-mortem is not needed, then the body is returned to the family and the coroner will issue their findings later.
5. If the coroner decides a post-mortem is needed, then the family has 24 hours to tell the duty coroner if they don’t want the post-mortem to happen.
6. The post-mortem will be carried out at the nearest hospital where there is a mortuary and a pathologist.
7. Before the pathologist examines the body, two people who knew them must officially identify the body.
8. A pathologist will complete the post-mortem as soon as possible.
9. You can request to view or be near your loved one while they are in the coroner’s care. You will need to talk to the duty coroner’s office for more information and to request this.
10. Once the post-mortem is completed, the body can be released from the mortuary to the family (you can also ask for the return of tissue samples if you would like). You will either need to have the body picked up by a funeral director, or you can do this yourself.
11. If the cause of death is still undetermined after the post-mortem, then the coroner will decide that an inquiry is needed.
12. The pathologist will give the coroner a provisional report which will state the cause of death. The final report can take a few months, or even longer depending on the examination. The immediate family will receive a copy of the post-mortem report (unless it is part of a police investigation), the coroner’s findings and any recommendations that are part of the findings. A representative from Coronial Services will pass this information on to the family, which you might want to discuss with your doctor as it could include complex medical language and distressing content.

The coronial inquiry process

If the cause of death is still undetermined after the post-mortem, then the coroner will decide that an inquiry is needed. The coronial inquiry will determine the facts of the death, who the person was, and where, when and how the person died.

If a coroner believes that more evidence needs to be determined, they will hold a hearing in court. This is called a coronial inquest. This takes place in court and the coroner will hear from witnesses and consider evidence gathered from medical investigations (a post-mortem or doctor’s report) or occupational safety and health investigations.

A coroner might not hold a formal inquest if they believe they already have the evidence they need. An inquiry is required by law in a few circumstances. These include if a person has died:

• In police custody, or in prison
• In an Oranga Tamariki home
• In foster care or if they were a ward of the state
• Under a mental health compulsory treatment order
• In an institute for drug and alcohol rehabilitation
• Intellectually disabled and in compulsory care or rehabilitation

You can apply for a non-publication order that ensures specific details or evidence given during a coronial inquiry cannot be made available to the public, in the media or online.

A hearing in court or ‘on the papers’

A hearing is called during the end of the coronial inquiry where the coroner will assess all the information and evidence gathered and make a final decision on how the person has died. The hearing will either be held in a courtroom where the coroner will hear from witnesses (called an inquest) or the coroner will make a finding in their office/chambers after reading all the evidence.

The coroner’s findings is a report written by the coroner determining the facts of the death. Findings can also include recommendations or comments to help prevent similar deaths in the future.

Find out more about inquests and hearings on papers.

Key contacts during the coronial process

It is easier if there is one nominated representative from the family to be the key contact person throughout the process. Your key contacts will be:

• A National Initial Investigation Office Coordinator who manages the case and keeps you up-to-date with what’s happening throughout the process.
• The Coronial Case Manager will help you if you would like to talk to the coroner. You can contact the regional office responsible for any active case or if you are unsure whether the case is active or in which region, you can email or phone either 04 918 8332 or 04 466 2786.