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Coronial Inquests - A Guide for Nurses

Writer: Daniel Gosewisch
Daniel Gosewisch
Oct 8
3 min read


Receiving correspondence from the Coroner's Court can be confronting. Many nurses worry that being called to a coronial inquest means they have done something wrong.


However, being called as a witness does not mean you are accused of wrongdoing. Witnesses are often asked to attend because they were involved in a person's care or have information that may assist the Coroner in understanding the circumstances surrounding a death.


This guide explains what a coronial inquest is, your obligations as a witness, the support your employer may provide, and when it may be appropriate to seek legal assistance.


What is a Coronial Inquest? 

A coronial inquest is a court proceeding conducted by a Coroner to investigate a reportable death.

The Coroner seeks to identify the deceased, determine when and where the death occurred, understand how the death occurred, and consider whether recommendations could improve safety or prevent similar deaths. The inquest is not conducted to determine criminal or civil liability. 


If You Are Called as a Witness

A summons or notice may require you to attend the inquest, give evidence under oath or affirmation, produce relevant documents or records, or do a combination of these things. The correspondence should be read carefully so that you understand exactly what is required and by when. 

If you are lawfully summoned, you will generally be required to comply. 


Preparing to Give Evidence

Preparation should begin by reviewing the clinical notes, records and any earlier statement relating to the events. This is intended to refresh your memory rather than reconstruct it. If any aspect of the process causes concern, discuss it with your union representative or lawyer before the hearing. 

 

You may wish to seek legal advice if your interests may diverge from your employer’s. Your evidence should be based on your own knowledge, recollection, and records. 


Your Obligations as a Witness

(a)  Attend When Required

If you are summoned to attend, you must attend at the specified time and place unless formally excused by the court and failure to attend without a valid reason may result in penalties or other enforcement action. 

(b)  Tell the Truth

Before giving evidence, you will usually be asked to swear an oath or make an affirmation that you will tell the truth. When giving evidence, answer each question honestly and only to the extent of your knowledge and recollection. It is important to acknowledge when you do not know or cannot remember something, and to correct any answer if you later realise it was mistaken. 

It is perfectly acceptable to say: 

  • “I don’t know.”  

  • “I can’t recall.”  

  • “I would need to review my records.” 

(c)  Answer Relevant Questions

Witnesses are generally required to answer questions relevant to the matters being investigated.

The Coroner has broad powers to obtain information necessary to determine the circumstances of the death. 


(d)  Produce Relevant Documents

You may be required to provide records, clinical notes, reports, emails, photographs, or other materials relevant to the investigation. Relevant material must be preserved in its original form. Records should not be altered, deleted, recreated as though they were original, or destroyed once they may be relevant to the coronial investigation.

 

Your Employers Obligations

Your employer may assist you with administrative matters associated with the inquest, such as locating records, arranging leave to attend court, coordinating access to relevant documents, and facilitating legal representation where available. 


It is also common for employers to undertake their own preparation for an inquest, including reviewing records, briefing legal representatives, and preparing organisational witnesses. 


Your employer must not interfere with the coronial process or your evidence. Although an employer may assist with preparation and practical arrangements, the employer should not direct the substance of your evidence, pressure you to change your recollection, discourage truthful evidence, request alteration or destruction of records, or retaliate because you participated in the inquest. 


If you disagree with your employer’s view of events, or if you are concerned that someone is attempting to influence your evidence, seek legal advice as soon as possible. Witnesses should never feel pressured to provide evidence that is incomplete, inaccurate, or inconsistent with their genuine recollection. 

Your primary obligation is to the Court 

Your evidence must be truthful, independent, and based on your own knowledge and recollection. If you feel pressured by an employer or anyone else regarding your evidence, seek legal advice immediately. 

If Concerns Arise During the Inquest

If a question appears to have personal legal implications, raise the concern with the Coroner and request an opportunity to obtain legal advice. You should then follow any direction given by the Court rather than refusing to answer on your own initiative. 


Regardless of any concerns, your responsibility remains the same, provide truthful evidence based on your recollection and the available records. If you do not know or cannot remember something, it is entirely appropriate to say so. 

 
 
 

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