Legal Processes

Coroner’s Inquiry


  1. A Coroner’s Inquiry (‘CI’) is an inquiry conducted by a Coroner into the circumstances leading to a death. It is governed by the Coroners Act (Cap. 63A) (“Coroners Act”), which came into effect on 2 January 2011. A CI is a fact finding and not a fault finding process, the purpose of which is for Coroner to ascertain (a) the identity of the deceased, and (b) how, when and where the deceased came by his death.
  2. The Coroners Act sets out the instances when a CI is mandatory. These include a death that occurred under suspicious circumstances. The Coroners Act also requires the Police to investigate deaths which has to be reported under the Coroners Act ("reportable death"). When information of a reportable death is received, the Police will investigate into the circumstances leading to the death in question and report their findings to the Coroner. Such investigations may include:
    • Seizing relevant exhibits at the scene of death (such as suicide notes, samples of substances suspected to have been consumed by the deceased, weapons, machines/objects believed to have caused death and items used/left behind by the deceased prior death);
    • Taking photographs at the scene of death (of the scene and the deceased);
    • Obtaining relevant documents (such as the autopsy report and the toxicology report of the deceased);
    • Recording statements from persons who witnessed the occurrence of death or who were in contact with the deceased shortly before death;
    • Checking the background of the deceased (such as personal particulars and family background, financial and insurance details, medical and psychiatric history and educational and employment records);
    • Obtaining the opinion of an expert witness, where necessary, e.g. a medical opinion relating to a cause of death.


  1. The Coroner may give directions concerning such investigations into reportable deaths. Where it is considered appropriate, the Coroner, or the Public Prosecutor, may direct a forensic pathologist to investigate into the cause and circumstances of the death. An example of such a circumstance will be a case involving complex medical issues. Such forensic pathologist is conferred with specific statutory powers under the Coroners Act and shall regularly update the Coroner and Public Prosecutor, as well as the police officer investigating the case.

Parties to the CI

  1. In appropriate cases, a State Counsel from the Attorney-General’s Chambers may be assigned to assist the Coroner for the purpose of the CI. In this connection, the State Counsel will work closely with the Investigating Officer to present the evidence at the CI.
  2. Persons who qualify as a “properly interested person” may attend and examine witnesses at the CI. Such a “properly interested person” includes:
    • The spouse or next-of-kin of the deceased;
    • The personal representative of the deceased; or
    • Any person who, in the opinion of the Coroner, should be regarded as having any particular interest in the inquiry.
  3. Other parties who may attend the inquiry include:
    • Representatives from the Embassy of the deceased’s country of birth or domicile, if the deceased is a foreigner; and
    • Counsel acting on behalf of an interested third party such as a hospital or an insurance company.
  4. The Coroner has all the powers of a Magistrate’s Court with regard to summoning and compelling the attendance of witnesses as well as the production of any document or thing at the CI.

Pre-Inquiry Review

  1. Prior to the hearing of the CI, a pre-inquiry review, also commonly known as a Coroner’s Mention, will be conducted by the Coroner. The purpose of the pre-inquiry review is to settle legal (e.g. evidential matters such as the Investigation Report and conditioned statements of witnesses) and administrative issues (e.g. fixing the date of the CI) with a view to expediting the CI.

The Inquiry

  1. A CI will be held in open court, unless the Coroner has sufficient reason not to do so. In such a case, the Coroner has to report his reasons to the Public Prosecutor. Where the issue at hand is sufficiently complex and the Coroner considers it appropriate, he may appoint not more than two assessors with skill and experience in the subject matter of the inquiry to assist and advise him in the hearing.
  2. It is reiterated that a CI is a fact finding and not a fault finding process. It is not a criminal trial involving the prosecution of an accused person. The Coroners Act specifically prohibits the Coroner from framing a finding to determine any question of criminal liability. The purpose of a CI is for the Coroner to ascertain the identity of the deceased; and how, when and where the deceased came by his death. The role of the State Counsel is to assist the Coroner in achieving this purpose.
  3. In this regard, the State Counsel will assist the Coroner by presenting the evidence gathered by the investigation to the matter. Such evidence includes (a) the Investigation Report by the Investigating Officer (b) documentary evidence such as the Autopsy Report and Toxicology Report of the deceased (c) conditioned statements of the relevant witnesses and (d) the report (if any) of an expert witness e.g. a medical opinion on a possible cause of death.
  4. Consistent with the fact finding objective, the Coroner is not bound by the rules of evidence and may conduct the CI in any manner he reasonably thinks fit. Where necessary, the Coroner may require a witness to give evidence in person. The witness will have to give his testimony under oath from the witness stand. Apart from the State Counsel and a properly interested person, any other person may examine such a witness with the permission of the Coroner.

Coroner’s Findings

  1. At the conclusion of a CI, the Coroner will record his findings as to the identity of the deceased and how, when and where the deceased came by his death. Common examples of findings made by the Coroner include “suicide” or “misadventure”. Thereafter, the Coroner shall forward a copy of the certificate setting out the cause of death as found at the CI, to the Registrar-General of Births and Deaths and the Public Prosecutor.