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A coroner holds an inquiry to find out more about who the person was, and where, when and how they died. Inquiries also help coroners make recommendations or comments that might prevent a similar death happening in the future.

Inquiries are usually opened soon after the death but sometimes it can take a few weeks for the coroner to decide if there should be an inquiry.

Coroners don’t hold inquiries into all deaths reported to them

Sometimes, a coroner will ask for another investigation to help them decide if they should hold an inquiry. This can include medical investigations (like a post mortem or doctor’s report) or occupational safety and health investigations.

Sometimes – like when it’s a natural death – they may make a finding without having to open an inquiry.

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When there has to be an inquiry

There has to be an inquiry if the person appears to have died from unexplained, violent or suspicious circumstances.

There has to be a compulsory inquest if the person who died was:

  • in police custody
  • in prison
  • in a Ministry for Vulnerable Children, Oranga Tamariki home
  • in foster care or if they were a ward of state
  • under a mental health compulsory treatment order
  • in an institute for alcoholism or drug use
  • intellectually disabled and in compulsory care or rehabilitation.

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Family can be involved as much as they want to be

Coronial Services will make sure the family of the person who died are kept up to date with what’s happening.

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Putting an inquiry on hold

Sometimes the coroner adjourns the inquiry (puts it on hold) until other investigations are finished, such as a police prosecution or an investigation by the Department of Labour or the Health and Disability Commissioner.

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Coroners can hold a hearing in court or ‘on the papers’

A hearing happens towards the end of an inquiry. This is when the coroner decides on the facts of the death.

At a hearing ‘on the papers’, the coroner makes a finding in their office (chambers) after reading all the evidence.

If the coroner needs to hear from witnesses in person, they will hold a hearing in court. This is called an inquest.

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Coroner’s finding

A finding is a report written by the coroner about the facts of the death. The finding can also include comments or recommendations to help prevent similar deaths in the future.

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