Chapter 15: Post-mortem examinations and coroners cases

Public Health Regulation 2022 

The Public Health Regulation 2022 commenced on 1 September 2022.  

The Regulation makes provision for disease control measures and the the facilities and procedures for the handling of bodies of deceased persons, exhumations, cremations and other matters relating to the disposal of bodies. 

Find out more.

Post-mortem examinations

A post-mortem examination or autopsy usually involves an internal and external examination of the body. Organs, tissues and body fluids are examined and small samples may be taken if necessary. An autopsy is performed by a doctor who has special training and experience in this field (called a forensic pathologist). The pathologist writes a full report of their findings.

The purpose of a post-mortem examination is to better understand the factors that may have contributed to the person’s death. This information may be important for the next of kin (eg if the person died from an infectious or genetic disease), or for the community as a whole (in identifying or tracing outbreaks of disease) or it may be used for teaching purposes or to monitor the quality of the hospital’s diagnostic and treatment procedures. The report will be made available to the senior next of kin or their delegate and to a medical practitioner nominated by the relatives of the deceased

Hospitals sometimes request permission from the next of kin to perform post-mortems, for example for research or teaching purposes. This is called a hospital (or non-coronial) autopsy. All hospital autopsies require consent from next of kin. An autopsy can also be requested by the deceased’s family if they have good reasons for the request. An autopsy request can also be limited to a particular area of the body.

Coroner 's post-mortems

The coroner requires a post-mortem examination to determine the cause of death in cases referred to them (see Coroner’s cases below).

The post-mortem is carried out by a doctor who has special training and experience in this field, and who has written authorisation from the coroner to perform the examination. It is carried out in a forensic mortuary or a hospital authorised to perform a forensic post-mortem, and a report is sent to the coroner.

Objecting to a post-mortem

Next of kin can object to a post-mortem by writing to the coroner explaining their reasons for the objection. The coroner decides whether a post-mortem is necessary or is in the public interest. The coroner must give immediate notice of that decision to the next of kin.

Unless the coroner believes the post-mortem examination must be performed immediately, it must be delayed for 48 hours to allow the next of kin time to apply to the Supreme Court for an order to stay the examination. If it is satisfied that it is desirable in the circumstances, the Supreme Court may make an order that no examination, or only a partial examination, be performed.

Availability of reports

Post-mortem reports and other medical reports are available free of charge to the senior next of kin or their delegate and any person who the coroner believes has ‘a sufficient interest’ in the circumstances of the death, such as the deceased person’s medical practitioner.

After the post-mortem

When the post-mortem examination is completed, the coroner will allow the body to be taken by the funeral director chosen by the family. Usually, consent for the funeral is given straight after the post-mortem, even if the results are not available. If the next of kin choose a cremation, they have to complete an Application for Permission for Cremation and be issued with a Coroners Cremation Permit. These forms can be found on the NSW Health web page Final arrangements of the deceased.

Coroner's cases

A coroner’s role is to inquire into deaths that are sudden or unexpected, or where the cause of death is unknown. Coronial services in NSW are coordinated by the State Coroner, located in Lidcombe. All magistrates of the local court are coroners. Registrars at local courts in most towns throughout NSW are also coroners or assistant coroners.

A medical practitioner must not issue a certificate as to cause of death if the death is a ‘reportable death’ under the Coroners Act 2009 (NSW). A ‘reportable death’ is defined in section 6 of the Coroners Act as where a person has died:

  • a violent or unnatural death
  • a sudden death the cause of which is unknown
  • under suspicious or unusual circumstances
  • in circumstances where the person’s death was not the reasonably expected outcome of a health-related procedure carried out in relation to the person
  • while in (or temporarily absent from) a mental health facility while the person was a resident at the facility for the purpose of receiving care, treatment or assistance.

Or, under section 23 of the Coroners Act, if the death is a death in custody, where a person has died:

  • while in the custody of a police officer or in other lawful custody
  • while escaping, or attempting to escape, from the custody of a police officer or other lawful custody
  • as a result of, or in the course of, police operations
  • while in, or temporarily absent from a detention centre, a correctional centre or a lock-up
  • while proceeding to a detention centre, a correctional centre or a lock- up for the purpose of being admitted and while in the company of a police officer or other official charged with the person’s care or custody.

Or, under section 24 of the Coroners Act, if the death is a death of a child who was:

  • a child in care, or
  • a child in respect of whom a report was made under the Children and Young Persons (Care and Protection) Act 1998 (NSW) within the period of three years immediately preceding the child’s death, or
  • a child who is a sibling of a child in respect of whom a report was made under the Children and Young Persons (Care and Protection) Act 1998 within the period of three years immediately preceding the child’s death, or
  • a child whose death is or may be due to abuse or neglect or that occurs in suspicious circumstances.

Or the death of a disabled person who was:

  • living in, or temporarily absent from, specialist disability accommodation or an assisted boarding house
  • a person who received assistance from a service provider to enable the person to live independently in the community.

In any of these circumstances the medical practitioner must immediately notify the police so that the coronial procedure can begin. Every death reported to the coroner must be investigated to determine the cause of death.

The deceased must be formally identified to the police by someone who knew them, and the police must complete a report of death to the coroner.

Documents and information

The coroner also issues the coroner’s form of information of death, which is sent to the NSW Registry of Births, Deaths and Marriages. From this form, the registrar completes the cause of death on the death certificate and can then issue the death certificate to the executor or next of kin. The certificate may be issued without a cause of death stated if the coroner’s form had not been received when the certificate was requested.

Help with Coroner's cases

Coronial information and support

The Coronial Information and Support Program (CISP) is designed to provide information and support for those families affected by sudden death in New South Wales, including face to face and telephone support for people during the coronial process. The CISP can refer family and friends of the deceased to a counselling service.

Counselling units are available through the Department of Forensic Medicine in Lidcombe, Wollongong and Newcastle and provide access to forensic counsellors (social workers). They can provide information, support and bereavement/trauma counselling for families and friends involved in the coronial process. 

Coronial Inquest Unit

The Coronial Inquest Unit is a statewide specialist service of Legal Aid NSW. They provide free legal advice and assistance in coronial matters, and represent people at coronial inquests where legal aid has been granted.

Legal Aid is available for representation at inquests within NSW where a public interest test is satisfied, or in all cases involving the death of an Aboriginal or Torres Strait Islander in custody.

Coroner's inquests

Once the initial investigation is complete, the coroner decides if an inquest should be held. An inquest is a public hearing before a coroner to find out the date, place, cause and manner of death, and the identity of the deceased.

If the investigation reveals evidence of an indictable offence by a known person, and the coroner believes the evidence would satisfy a jury beyond reasonable doubt, the coroner must refer the case to the Director of Public Prosecutions.

In most cases, the results of the post-mortem and preliminary police investigations will establish that death was by natural causes and an inquest will not be necessary. Under the Coroners Act an inquest can be dispensed with in a broad range of cases. All murders involve an inquest, except where someone has already been charged in connection with the death.

If an inquest is not held

If an inquest will not be held, the coroner will notify the next of kin of this decision in writing. Any person who is considered to have ‘sufficient interest in the circumstances of the death’ may ask the coroner why an inquest was not held. If next of kin are unhappy about the coroner’s decision not to hold an inquest, they may write to the coroner to ask for an inquest and give their reasons for wanting it.

Next of kin should find out all they can about coronial inquiries and the associated advantages and disadvantages before making a decision to request one. Information is available from the Coroners Court.

If an inquest is to be held

If an inquest is to be held, the coroner will send the details of the time, date and place of the hearing to the next of kin. If you are not the next of kin, you should write to the coroner as soon as possible and ask for the details of the inquest.

The Coroners Court

Inquests are held in the Coroners Court. They are not bound by the normal rules of evidence and procedure. The coroner normally hears all the evidence alone, but the State Coroner can direct that proceedings be held before a jury.

At the inquest, all interested parties have a right to appear and to be legally represented. Parties must give the coroner notice in writing if they wish to appear. It is then the coroner’s responsibility to inform the parties of the time and place of the inquest.

All witnesses called to give evidence must do so. They may be questioned further about their evidence by an interested party or a solicitor acting for that party.

An inquest hearing in court may take less than a day or up to a few weeks to complete. At the end of an inquest, the coroner will make a finding as to the circumstances of the death and may make recommendations to the relevant authorities. If the coroner decides that there is a case against any person for any serious offence, a record of the inquest is forwarded to the Director of Public Prosecutions. The Director of Public Prosecutions may decide to proceed against the person concerned, in which case they will be charged and tried in court in the usual manner.

If next of kin are not satisfied with the outcome of the inquest, it may be possible to have another one held. They should seek legal advice before proceeding with this course of action.


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