Coronial Inquests in Victoria Explained: The Process and the Bourke Street Mall Inquest

After being involved in a complex Coronial Inquest, Associate, Anastasia Nagorny, prepared some introductory information for families navigating the processes of the Coroner’s Court.

At Brave Legal, our team has extensive experience in assisting and representing families throughout the Coronial Inquest process.

We hope this article helps answer some of the most common questions our team gets asked during this difficult time.

What is the role of the Coroner’s Court?

The role of the Coroner’s Court of Victoria is to investigate deaths and fires, and to make recommendations aimed at preventing similar incidents in the future.

The Coroners Act 2008 (the Act) states that a Coroner must investigate a ‘reportable death,’ which is defined as follows:

• the body is in Victoria;
• the death occurred in Victoria;
• the cause of death occurred in Victoria;
• the person ordinarily resided in Victoria at the time of death.1

Additionally, to meet the criteria for a ‘reportable death,’ the death must occur under specific circumstances outlined in the Act. These include, but are not limited to:

• the death appears to have been unexpected, unnatural, violent, or the result of an accident or injury;
• the death occurred during or following a medical procedure;
• the death of a person who was a patient under the Mental Health and Wellbeing Act 2022;
• the death of a person whose identity is unknown.2

What is an Inquest?

An Inquest is a formal hearing in which the Coroner hears evidence from various witnesses and considers submissions from the parties involved. The Coroner will then deliver their findings, including the cause of death, and may make recommendations (such as those related to policy).

The length of the Inquest is dependent on each individual case and the volume of evidence, such as the number of witnesses involved. An example of this is discussed in a Case Study below.

Not every death investigated by the Coroner results in an Inquest. Inquests are generally held when the circumstances of the death or fire are unclear, or when there are significant public health and safety concerns that require further examination. These factors influence the Coroner’s decision to hold an Inquest.

What is the role of the Coroner?

A Coroner is a judicial officer responsible for investigating reportable deaths and fires. Coroners are generally Magistrates or Australian lawyers with at least five years of practising experience. However, the State Coroner must be a Judge of the County Court, and the Deputy State Coroner must be a Magistrate.3

The Coroner’s first step, before deciding whether an inquest is necessary, is to investigate the reportable death. This investigation may involve ordering an autopsy, conducting further tests, gathering statements from witnesses, obtaining medical records and/or any further information and reports related to the death.

Based on this investigation, the Coroner may determine that there is sufficient information to establish the cause of death, in which case they will deliver their findings without an Inquest.

If the cause of death is still unclear, the Coroner may then decide that holding an Inquest is necessary.

Families can request an Inquest, and their application will be considered by a Coroner. An application can be made once the Coroner has had time to gather and review the evidence.

The goal of an Inquest is not to find someone guilty or assign blame, but to determine the facts related to the death or fire.

Case study

In 2017, a horrific incident occurred on Bourke Street, in which six people tragically passed away after being struck by a car that drove through Bourke Street Mall. This incident was highly publicised, and the tragic deaths were investigated by the Coroner’s Court.

An inquest was held as the deaths met the definition of ‘reportable death’ under the Act, being unexpected, violent and resulted directed from injury.4

The Inquest spanned 31 days due to the large volume of evidence.

In her findings, Coroner Jacqui Hawkins stated the identity of the deceased individuals, their dates and causes of death, and the circumstances in which they died.

Additionally, Coroner Jacqui Hawkins made twelve recommendations in connection with the deaths, some of which are briefly summarised as follows:

• that Victoria Police, together with the Department of Justice & Community Safety investigate the use of Victoria Police issued body-worn cameras to record all out of sessions bail and remand hearings;
• that Victoria Police review their criminal investigator and investigator management training programs.

How do I report a death?

To report a death, and anyone who thinks a reportable death has occurred, should contact Coronial Admissions and Enquiries on 1300 309 519. This line is available 24 hours a day, seven days a week.

A link to the relevant Coroner’s Court of Victoria webpage is provided here.

Can families participate in inquests?

Yes, families can participate in an Inquest.

It is not a requirement that families must be legally represented at an Inquest. This is an option that is available but is not compulsory.

Families may choose to be legally represented if they wish to take a more active role in the Inquest. They can engage a solicitor and a barrister (also known as counsel who specialise in advocacy) who will be able to cross-examine witnesses and address the Coroner directly at the Inquest, including by making submissions on their behalf.

It is not the role of the Coroners Court to assist families in choosing their legal representatives. This is done independently.

For some families, this level of involvement is necessary, while for others it may be distressing. It is entirely up to each family to decide whether to seek legal representation, and they will not be criticised for choosing to have, or not have, legal representation.

If families choose not to seek legal representation, the counsel assisting the Coroner, a solicitor or a barrister (and commonly referred to as ‘Counsel Assisting’) can assist families in navigating the coronial process.

Coronial Inquests are usually not conducted on a no-win, no-fee basis as there is no potential for costs recovery or link to any compensatory outcome. However, if a personal injury claim is contemplated as a result of an injury suffered by someone close to the deceased, it is possible to recover the costs of an Inquest when the personal injury claim resolves.

For further information, please visit the link below to the Coroner’s Court of Victoria website, linked here.

Families attending an inquest have the option to choose whether or not they wish to be legally represented.

Our dedicated team is here to advise and guide you through the Coronial system. For a confidential discussion about a Coronial Inquest, please contact Brave Legal on 03 9070 9816.

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1 Section 4(1) Coroners Act 2008 

2 Section 4(2) Coroners Act 2008 

3 Coroners Act 2008 (Vic) ss 91- 94

4 Coronial Inquest into the deaths of Matthew Poh Chuan Si, Thalia Hakin, Yosuke Kanno, Jess Mudie, Zachary Matthew Bryant, Bhavita Patel (Coroners Court of Victoria, Coroner Jacqui Hawkins, 19 November 2020).