When the country’s top coroner tells people what she does, many have no idea what she means.
“Some people think I’m a pathologist, so they say things like, ‘how does a small person like you cut up bodies? And I say, ‘no – that’s a pathologist, not a coroner’.”
The Chief Coroner, Judge Deborah Marshall, pins some of the confusion on the popularity of coroner-themed television programmes. She points to the British series The Coroner, in which the main character “spent all her time running around the countryside with her detective colleague, solving crimes and deciding causes of death”.
The reality, she says, is quite different.
“Coroners run a 24/7 system, so every day, night, weekend, and public holiday there’s a coroner on duty … and they’re on duty for the whole country. So every death that’s reported is reported to the duty coroner.”
Those deaths include any death not from natural causes – unless a doctor can’t rule a cause of death, in which case the coroner still gets the call.
Coroners also identify bodies, often through dental records or by bringing in the next-of-kin.
Judge Marshall says coroners don’t even get in the same room as bodies.
“Because the duty coroner’s covering the whole country and might have 20 deaths reported in one day, it’s impossible - and there’s no need. The police are our agents for that purpose, so they’ll go to the scene of a death and take photographs, interview people … and then they feed all that information back to us.”
Once a death is referred to the duty coroner, they then decide whether to conduct a post-mortem examination, and ultimately, whether the case requires further investigation. The body is generally passed back to the family’s undertaker at this point.
If an investigation is needed, the file is passed to a ‘cluster coroner’ based in the region near where the person died. Then, the digging begins.
“For example, the police will have taken statements from people at the scene but I might think a statement from their GP might be helpful, so we write to the GP and ask for their clinical history.”
They also work with the police's Serious Crash Unit, and WorkSafe, to collect information.
“Once the coroner has all the information, they’ll look at it and say, ‘are there any issues that are disputed?’”
If so – for example, if doctors disagree on whether something went wrong – a case goes to an inquest.
A family also has the right to cross examine witnesses, and if they want to do so, an inquest must be held. Inquests also take place in complex cases where it makes more sense to gather all the witnesses in one place.
“We aren’t able to establish criminal or civil liability, so we can’t say that person killed X , but we can establish the cause and circumstances of the death.”
Judge Marshall says the proportion of cases which go to an inquest is very small, “partly because of the huge workload that coroners carry”.
Each coroner has between 200 and 300 active cases, but they also have to juggle the duty work.
“I think in Australia and New Zealand the inquest rate is falling because of the work overload. So I’d say it’s certainly fewer than 10 percent of our cases would go to inquest. The rest are done on the papers.”
When asked if that was worrying, Judge Marshall is diplomatic.
“I think most coroners would say you’re going to find out more by holding an inquest because it’s that ability to look at a witness and ask question after question.”
A coroner’s recommendations hold no legal weight, but often suggest changes to an agency’s practice or recommend law changes be implemented.
It’s frustrating, however, when warnings aren’t heeded; specifically, she says, in cases of cot death.
“A file comes across your desk when a child’s sleeping in an adult bed… and they’re found dead in the morning. And you think to yourself, here we go again, where I’m going to make that same recommendation that every sleep should be a safe sleep.”
Judge Marshall says she enjoys the job “most of the time” – it’s varied, and she enjoys the investigative side and working with other agencies and coroners.
But it’s tough.
“We refer to the daily diet of death. Every file we deal with ends with the paragraph, and then they died. It can take a toll.”