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Dealing with coroners

4 Aug 2020

Medical Protection receives a significant number of calls from members seeking assistance in providing evidence to the coroner. We are happy to review Coroner’s reports for our members, prior to submission, or can be contacted to answer other questions relating to the Coronial process through our advice line 0800 2255677. This factsheet aims to provide background information on the Coronial process, but if more specific information is required, our members should contact us directly.

Reported deaths

Only deaths that are unexpected, of unknown cause or of individuals in official care or custody, or that occur in relation to medical or surgical treatment, appear to be self-inflicted, violent or related to childbirth and pregnancy, must be reported to the coroner. However, there can be other circumstances where a doctor is unsure of the exact cause of death, where they may wish to contact the duty Coroner to discuss the case and to ascertain whether they should write a death certificate, or report the case to the Coroner, for their consideration. The duty Coroner can be contacted through the National Initial Investigation Office on 0800 266 800.

Coronial inquiries

Not all deaths reported to the coroner will lead to an inquiry. Sometimes the coroner may order investigations or examinations, medical or otherwise, to help decide whether to open an inquiry.

An inquiry must be opened into all deaths that occur in official custody or care, or which are self-inflicted (apparent suicide).


The purpose of a coronial inquiry is to formally establish the causes and circumstances of a death. A coroner will open and conduct an inquiry for three purposes:

  1. to establish who the person was, and where, when and how they died.

  2. to make specific recommendations that may reduce the chances of other deaths occurring in similar circumstances.

  3. to determine whether public interest will be served by the death being investigated by another investigating authority, such as Land Transport New Zealand, etc.


An inquiry may be opened shortly after the death has occurred, but it may be some weeks before the coroner makes a decision on whether to hold an inquest, which is a public hearing to examine all the evidence. Not all inquiries will lead to an inquest and frequently the Coroner may make their decision ‘on the papers’, where they have come to their conclusion after reading all the evidence, without holding a hearing in court.

During an inquiry

During an inquiry, or at its conclusion, a coroner may make adverse comment on the conduct of a doctor involved in the care of a deceased patient. In all such cases, the doctor must be given an opportunity to respond to the proposed adverse comment before any final findings are made.

Adverse comment can lead to adverse publicity and be picked up by other authorities investigating the circumstances of the death, eg, the Health and Disability Commissioner (HDC) or the Medical Council may subsequently refer to evidence provided to a coroner, or the coroner’s findings.

If a Coroner has identified any concerns with practitioner's competence, he can refer those to the HDC or the MCNZ.

Requests for information

The coroner will often seek evidence from health professionals involved with the deceased, in addition to information from a postmortem examination. The coroner may also seek expert advice in areas requiring particular technical knowledge.

After notification of death, information is usually requested from a doctor by a police inquest officer, either verbally or written. As the police may also be investigating the death for other reasons, it is important to establish that the purpose of the officer’s request is to provide evidence to the coroner. Medical Protection recommends that members ask for requests from the police to be in writing, and that any statement given to the police is written in a format appropriate for the coroner.

A request for a report may also come from a Coronial Case Manager, who will be asking for a report on behalf of a specific Coroner.

Reports for the coroner

A report for the coroner must be clear, comprehensive and accurate, and answer any specific questions asked. It is an offence – punishable by summary conviction and a fine of up to $1,000 – for a statement to contain false or misleading information, or to knowingly or recklessly omit information.

Getting it right in the report is crucial to assist the investigative process and Medical Protection can assist members in doing what, for most members, will be an unfamiliar task. We have attached a template to this fact sheet to help our members in drafting Coroner’s reports, but would suggest they contact us for more specific advice.

Coroner’s inquiries and third parties

If it appears that charges will be laid in relation to a death it is likely that the coroner’s inquiry will be postponed until any criminal proceedings have been finally concluded. This can lead to a considerable period of time between death and the coroner’s inquiry. Investigations by other authorities, such as the HDC, may wait until a coroner’s inquiry is concluded before carrying out their investigation, or alternatively the Coroner may await an outcome from the HDC process before proceeding with an inquiry.

Further information

Download a PDF of the coroner's report template