Coroners Act 2003

A coroner may, whenever appropriate, comment on anything connected with a death investigated at an inquest that relates to—

public health or safety; or

the administration of justice; or

ways to prevent deaths from happening in similar circumstances in the future.

The coroner must give a written copy of the comments to—

a family member of the deceased person who has indicated that he or she will accept the document for the deceased person’s family; and

any person who, as a person with a sufficient interest in the inquest, appeared at the inquest; and

if the coroner is not the State Coroner—the State Coroner; and

if a government entity deals with the matters to which the comment relates—

the Attorney-General; and

the Minister administering the entity; and

the chief executive officer of the entity; and

if the comments relate to the death of a child—

the family and child commissioner; and

the chief executive (child safety).

The coroner must not include in the comments any statement that a person is, or may be—

guilty of an offence; or

civilly liable for something.