Findings on inquests
25 Findings on inquests
The
Coroner's Court must, as soon as practicable after the completion of an inquest, give its findings in writing setting out as far as has been ascertained the cause and circumstances of the event that was the subject of the inquest.
The
Court may add to its findings any recommendation that, in the opinion of the Court—
might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest; or
relates to a matter arising from the inquest, including (but not limited to) matters concerning—
the quality of care, treatment and supervision of the dead person prior to death; and
public health or safety; and
the administration of justice, and is, in the circumstances, an appropriate matter on which to make a recommendation.
However, the Court must not make any finding, or suggestion, of criminal or civil liability.
The
Court must, as soon as practicable after the completion of the inquest, forward a copy of its findings and any recommendations—
to the Attorney-General and any relevant Minister other than the
Attorney‑General; and
in the case of an inquest into a death in custody—
to each person who appeared personally or by counsel at the inquest;
and
to any other person who, in the opinion of the Court, has a sufficient interest in the matter.
Each relevant Minister must, within 8 sitting days of the expiration of 6 months after receipt of a copy of a recommendation resulting from an inquest—
cause a report to be laid before each House of Parliament—
giving details of any action taken or proposed to be taken in consequence of the recommendation; or
if no action has been taken or is proposed to be taken—giving reasons for not taking action or proposing to take action; and
forward a copy of the report to the State Coroner.
The
State Coroner may, at any time after the provision of a report under subsection (5), request a supplementary report to be prepared by the Minister that addresses any matter that the State Coroner considers necessary arising out of the report.
If the State Coroner makes a request under subsection (6), the Minister to whom the request was made must, within 8 sitting days of the expiration of 6 months after receiving the request—
cause a supplementary report to be laid before each House of Parliament addressing the matters requested to be addressed by the State
Coroner; and
forward a copy of the supplementary report to the State Coroner.
In this section—
relevant
Minister, in relation to findings and recommendations of the Court, means—
if a recommendation is directed to a Minister, or to an agency or other instrumentality of the Crown, as a result of the inquest—the
Minister to whom, or the Minister responsible for the agency or other instrumentality of the Crown to which, the recommendation is directed; or
in any other case—the Attorney‑General.
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