Joint inquests (2014/4)

1. Background

1.1.  Section 84 of the Coroners Act 2006 (“the Act”) provides that a Coroner may hold a single inquest that investigates more than one death.

1.2.  Coroners may consider it appropriate to use this provision in some circumstances for Inquiries into deaths which could be undertaken as a multiple death Inquiry to promote the purposes of the Act but in particular to assist in contributing to the reduction of the number of preventable deaths.

1.3.  Such an Inquiry would involve investigating multiple deaths during the course of an Inquest or Inquests or multiple hearing days of one “clustered” Inquest.

1.4.  This Practice Note is aimed at assisting in the proper and consistent consideration and co-ordination of the use of this power across the jurisdiction and to avoid unnecessary duplication of effort. Also to facilitate more appropriate recommendations or comments by drawing on a wider range of evidence than is possible by examining the circumstances of a death in isolation.

2. Guidelines for Consideration

2.1.  The following are a set of guidelines to use when a Coroner is considering the two or more deaths arising out of the same incident or series of incidents.

2.2.  A coroner may consider utilizing this power where there is a commonality of circumstance which give rise to it being appropriate to hear the cases as a group.

2.3.  The circumstances may include:

  • Environmental or mechanical similarity or commonality;
  • Multiple deaths at one location or type of location;
  • Multiple deaths arising from the use of one type or brand of equipment or product;
  • Multiple deaths which require the consideration of a common system or procedure or lack of a system or procedure;
  • Multiple deaths which require the involvement of one public authority in the care or management of the deceased;
  • Multiple deaths which appear to be linked by factors such as age, proximity and similar facts.

2.4.  Taking into account considerations such as those set out in paragraph 2.3, in determining whether it is appropriate to hear matters as a Joint Inquest, the Coroner should have regard to the factors set out in section 57 of the Coroners Act 2006 and in doing so will need to also give consideration to:

  • The likely impact including delay upon the interested parties under section 23 and 81 of conducting the proceedings in the manner proposed, in particular the affected families.
  • Any objections by interested parties to such a procedure being adopted.
  • Whether in hearing the matters together it may enable a broader inquiry to take place into the circumstances and thereby promote the section 3 purposes of the Act.
  • Whether in hearing the matters together it will enable a fair, timely, effective and efficient Inquiry to take place taking into account considerations such as the location of the hearing or hearings, the timing and duration of the Inquest or Inquests, the multiplicity of witnesses and their locations.

3. Process

3.1.  To avoid unnecessary duplication of types of Inquiry and to ensure appropriate allocation of resources, to enhance consistency of practice and decision making across the jurisdiction, and to ensure all Coroners are aware of relevant investigations underway, a Coroner proposing to utilize the power under section 84 must advise the Chief Coroner of his or her desire to do so.

3.2.  Upon receiving such notification, the Chief Coroner may make an enquiry as to any similar investigations already undertaken or currently underway and discuss with the notifying the Coroner and any other relevant Coroners.

3.3.  Once the decision has been made to proceed with a joint Inquest and has been approved by the Chief Coroner, the Chief Coroner will facilitate and co-ordinate the necessary administrative support pursuant to Section 116, and place the details into a register. This may include consideration of the provisions of section 133 to determine which Coroner or Coroners are to be involved.

3.4.  To ensure all Coroners and the public are aware of joint Inquests that either have been or are being undertaken, the Chief Coroner will provide details of these on a regular basis to all Coroners primarily by way of the Chief Coroner’s newsletter and the Ministry website.

Judge Neil Maclean
Chief Coroner
Date: 23 July 2014

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