Coroners, usually magistrates in your community, investigate deaths that are ‘unnatural’ such as accidents, suicides or homicides; deaths that have occurred in prison or in care, or have unknown causes. A coroner will investigate the circumstances surrounding the death, determine the cause of the death, and identify any public health or safety issues that caused the death.
The coroner may decide to hold an inquest. An inquest is a public hearing before the coroner where witnesses are called to give evidence. An inquest is usually held when the coroner decides that, based on police and medical reports, a formal hearing is needed to obtain and consider additional evidence.
At the conclusion of an inquest, the coroner may comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future. Comments and recommendations can, and often are, directed to us.
We think it is important to let you know we have considered each of the recommendations and comments Queensland coroners direct to us at inquests. We do this by producing an annual report. The report provides a response to each of the recommendations or comments directed to us and tells you if (and how) we plan to implement the coroners’ recommendations.
While nothing will compensate for the loss of a loved one, it is hoped that the families and friends of the people in these reports will receive some comfort from knowing that the recommendations aimed at preventing similar tragic deaths have been considered by us and in most cases implemented.
Many of the coronial recommendations in this report have been implemented, or are in the process of being implemented. The few recommendations in this report that are still under consideration by us will be responded to in next year’s report.
If you have any questions about the implementation of specific recommendations, please contact the responsible department named in the response in the report.
Read the 2012 response to coronial recommendations and previous coronial recommendations.