Victorian Coroners Court

This service description provides information about the role of the Victorian Coroner’s Court.
Document ID number 2708, version 2, 1 March 2016.

See procedure Death of a current or former client for tasks that must be undertaken.

for tasks that must be undertaken.


The Coroners Court investigates reportable deaths, reviewable deaths and fires. It does this to contribute to reducing the number of preventable deaths and fires through findings of investigations, and making recommendations.

Reportable deaths

A death must be reported to the coroner for investigation when it is classified as a reportable death. A reportable death includes (but is not limited to):

  • a death that appears to be unexpected, unnatural, violent or to have resulted from an accident or injury
  • a death that occurs during a medical procedure that was not reasonably expected
  • the death of a person who was placed in custody or care immediately before they died - this includes a child on a family reunification order, a care by Secretary order or a long-term care order, a child taken into emergency care and youth justice detainees
  • the death of a person under the control, care or custody of the Secretary to the Department of Justice or a member of the police force
  • the death of a person whose identity is unknown.

Reviewable deaths

A death must also be reported to the coroner for investigation when it is classified as a reviewable death. The death of a child is a reviewable death if the deceased child is a second or subsequent child of parents to have died. The coroner has the power to investigate a reviewable death and to refer the death to the Victorian Institute of Forensic Medicine (VIFM) to investigate the health and safety of any living sibling or the health of the parent of the deceased child institute will assess whether a report to child protection should be made in relation to living siblings. If required, the institute will make the report, and advise the State Coroner that the report has been made.

Functions of the Coroner’s Court

The primary function of the Coronor's Court is to investigate and make findings concerning the facts. The coroner does not attribute blame, but establishes the cause of death and in some situations the circumstances of death. Corners Court findings are required to be published on their website. See Coroners Court website.

The secondary function is to make recommendations on matters connected with the death, including public health or safety or the administration of justice. The coroner is not permitted to include any finding that a person is or may be guilty of an offence  and does not make any specific findings on whether there has been any negligence leading to the death in question.

The coroner can make recommendations to any minister, public statutory authority or any entity that may help prevent similar deaths.

Child protection and the Coroners Court

The coroner notifies Statutory and Forensic Services Branch (Child Protection Unit) of all reportable and reviewable deaths of children under eighteen years old. A CRIS search is undertaken to determine child protection involvement and whether there are matters of which the coroner should be aware. If the child is in scope for a child death inquiry, information is provided to the division or divisions connected to the case. Child protection practitioners may be required to provide statements to the coroner regarding child protection involvement and in some case may be required to give evidence during an inquest.

Coronial investigations

Every coronial investigation is different. It is up to the coroner to decide what investigation is necessary in each case. This can involve:

  • a review of the person’s medical history and the circumstances of the death
  • an autopsy and pathology tests
  • specialist reports from experts and external investigators, such as the police, doctors, engineers, the fire brigade, air safety officer, as well as statements from witnesses
  • an inquest to test all the evidence relating to the person’s death. (Only a small number of investigations result in an inquest. Most investigations are finalised by the coroner based on a review of the available evidence.)

For further information go to the Coroners Court website.


An inquest is a public hearing into a single death, multiple deaths or a fire, conducted by a coroner. In Melbourne, inquests are held in the Coroners Court. In regional Victoria, inquests are held at the local magistrates’ court.

An inquest is conducted using an inquisitorial approach. This allows for a greater investigatory role by the court when compared with the adversarial approach where two parties present cases to be adjudicated upon by a judge (the way trials are usually conducted).

The coroner has wide powers of inquiry and is not restricted to the normal courtroom rules about what evidence can be given. The coroner may hear from anyone who has information on the death. The coroner can order a witness to attend if necessary.

If a coroner or police on behalf of a coroner requests a statement regarding child protection involvement or if a child protection staff member is subpoenaed to attend an inquest at the Coroners Court, Legal Services Branch provides assistance.

Considerations for good practice

Emotional reactions

Usually, when someone dies, it is likely that a number of people associated with the person will experience significant emotional reactions. Particularly where a death occurs suddenly, unexpectedly or in traumatic circumstances the situation can feel overwhelming. Feelings of confusion, fear, guilt and numbness are common. It should be expected that reactions will vary widely. It would be unwise to make early judgements as grief reactions are unpredictable. However, should someone’s reaction raise concern it may be helpful to consider offering additional support or assistance.

Additional information