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THE CORONER's COURT

The task of the Coroner's Court is to inquire into the causes and circumstances of certain deaths. As this booklet outlines, the Coroner has extensive powers related to the conduct of affairs relating to such deaths.

What are the Coroner's powers?

The Coroner is a judicial officer who has the power to:

  • grant burial order
  • grant cremation order
  • grant waiver of autopsy
  • grant autopsy order
  • grant exhumation order
  • grant order to remove a dead body outside Hong Kong
  • order police investigation into the death
  • order inquest to be held
  • approve removal and use of body parts of the dead body
  • issue certificate of fact of death

What types of deaths should be reported to the Coroner?

The Coroners Ordinance sets out 20 categories of deaths (see Appendix I) which should be reported to the Coroner. Anyone responsible for reporting a death to the Coroner (see Appendix II) should do so as soon as they reasonably can after they know of the death.

What happens when a reportable death occurs?

The fact that a death is reportable to the Coroner does not necessarily mean that an inquest has to be held, except for certain categories of death. When a reportable death occurs, the body is sent to either a hospital or a public mortuary, where the pathologist:

  • conducts an external examination of the body
  • reports the findings of this examination and the cause of death, if ascertained, to the Coroner
  • recommends waiver of autopsy, and seeks a burial or cremation order if the cause of death can be ascertained
  • seeks an autopsy order if the cause of death cannot be ascertained
  • submits a brief description of circumstances connected with the death, for example, the clinical background.

The Coroner considers the pathologist's report and, depending on the case, makes the following orders:

  • autopsy order
  • waiver of autopsy
  • burial order
  • cremation order

If the Coroner is uncertain of the cause of death or for other reasons, he will:

  • order an autopsy
  • study the autopsy report from the pathologist
  • consider whether an investigation is needed

If the pathologist recommends an autopsy, but the deceased's family applies for a waiver and wishes to address the Coroner in person, the Coroner sees the family in chambers, and then decides whether to order an autopsy or a waiver. A waiver of autopsy will not be granted if the medical cause of death is not known.

If the Coroner decides that a reportable death should be investigated, the police carry out the investigation and submit a death investigation report to the Coroner. The Coroner considers this report and decides whether an inquest should be held, calling on expert opinion where necessary.

The Coroner may issue a warrant of entry and search in respect of any premises and place to search for things which may be relevant to a death.

If the Coroner decides not to hold an inquest, properly interested persons may request for a copy of the death investigation report.

Inquests

The Coroner may hold an inquest with a jury of five or without a jury when a person dies

  • suddenly
  • by accident or violence
  • under suspicious circumstances
  • when the dead body of a person is found in or brought into Hong Kong

An inquest must be held:

  • when a person dies whilst in official custody, for example, in a prison or a police cell (this inquest must be held with a jury)
  • upon the request of the Secretary for Justice

The Coroner may conduct a pre-inquest review to decide how the inquest may be disposed of in a just and expeditious manner. Pre-inquest reviews do not take place in open court, but inquests are held in open court.

Summons will be issued to witnesses to attend the inquest to give evidence and to produce documents. Legal representation for a properly interested person is allowed. Properly interested persons may upon payment of fees obtain copies of witness statements, medical or other technical reports.

The Duty Lawyer Scheme also provides legal representation to persons who are at risk of criminal prosecution as a result of giving incriminating evidence in the inquest.

In more complicated cases, the Coroner may request the Secretary for Justice to assign Government Counsel to assist him to hold the inquest.

What happens at the inquest?

At the inquest, the Coroner and the jury should ascertain:

  • the identity of the deceased
  • how, when and where the deceased died
  • the particulars required by the Births and Deaths Registration Ordinance to be registered concerning the death
  • the conclusion as to the death

The proceedings of the inquest are as follows:

  • the Coroner opens the inquest
  • witnesses are called and examined by the Coroner's Officer or Government Counsel, the jury, family members of the deceased, properly interested persons, and the Coroner
  • the Coroner sums up the case
  • the Coroner or the jury delivers the findings (typical examples of findings are set out in Appendix III)

The Coroner and jury are not allowed to frame a finding in such a way as to appear to determine any question of civil liability. Claims for civil liabilities and damages should be lodged and heard in the civil law courts.

Recommendations may be made if they are designed to prevent the recurrence of similar fatalities, for instance deaths in industrial accidents, to prevent other hazards to life disclosed by evidence at the inquest, or to bring deficiencies in a system or method of work to the attention of a person who may have power to take appropriate action.

The Coroner must adjourn an inquest and refer the matter to the Secretary for Justice where it appears that a criminal offence of murder, manslaughter, infanticide or death by dangerous driving may have been committed by any person. An inquest cannot be resumed until the criminal proceedings are finished.

Can anyone ask the Coroner to hold an inquest?

Properly interested persons or the Secretary for Justice may apply to the Court of First Instance of the High Court for an inquest to be held into a death including, where an inquest has already been held, a new inquest into that death. The jury who served in the first inquest will also serve as the jury for the re-opened inquest.

Certificate of the fact of death

The Coroner may also issue a certificate of the fact of death. This is in effect an interim document certifying the fact of death. The certificate of the fact of death can be used, for example, to assist in the transport of a dead body to another country for burial, in particular where the relevant authorities of that country require official documentation that the deceased did not die from an infectious disease.

Performance Pledge

The Coroner's Court will

  • grant a burial order
as soon as practicable upon the receipt of an application
  • grant a cremation order
  • grant an exhumation order
  • grant an order to remove a dead body outside Hong Kong
  • grant a waiver of autopsy
  • grant an autopsy order
  • issue a certificate of fact of death
10 days after receipt of the post-mortem report
  • list an inquest
42 days from the date of the Coroner's decision to hold an inquest

How to contact Coroner's Court?

Business Hours

Registry and Accounts Office

Monday to Friday 8:45 a.m. to 1:00 p.m.
  2:00 p.m. to 5:30 p.m.

(Closed on Saturdays, Sundays and Public Holidays)

What are the arrangements of the Coroner’s Court in case of bad weather?

Please refer to Typhoon and Rainstorm Warning Arrangements in the Judiciary website or radio/ television announcements of the same.

Appendix I - The 20 Categories of Reportable Deaths

  • Death the medical cause of which is uncertain
  • Medically unattended within 14 days prior to the death, except where the person was diagnosed as having a terminal illness before his/her death
  • Death caused by an accident or injury
  • Death caused by a crime or suspected crime
  • Death caused by an anaesthetic or the deceased was under the influence of a general anaesthetic or which occurred within 24 hours after the administering of a general anaesthetic
  • Death caused by an operation or which occurred within 48 hours after a major operation
  • Death caused by an occupational disease or which is directly/indirectly connected with the person's present/previous occupation
  • Still birth
  • Death of a woman which occurred within 30 days after the birth of her child/an abortion/a miscarriage
  • Death caused by septicaemia with unknown primary cause
  • Suicide
  • Death in official custody
  • Death occurred during discharge of duty of an officer having statutory powers of arrest or detention
  • Death in the premises of a Government department, any public officer of which has statutory powers of arrest or detention
  • Death of certain mental patients (as defined by law) in a hospital or in a mental hospital
  • Death in private care premises
  • Death caused by homicide
  • Death caused by administering of a drug or a poison
  • Death caused by ill-treatment, starvation or neglect
  • Death which occurred outside Hong Kong where the body of the person is brought into Hong Kong

Appendix II - Persons Responsible for Reporting Deaths

Person Responsible for Reporting Death Report made to
The registered medical practitioner who signed the certificate of the cause of death or attended the deceased during his/her last illness Coroner with a copy to the Commissioner of Police at the same time
The person in charge of a hospital, or another person authorized in writing by the person so in charge Coroner with a copy to the Commissioner of Police at the same time
Any person (except a police officer) exercising the duty of official custody Coroner via the Commissioner of Police
Any police officer exercising the duty of official custody Coroner
Any person in charge of a premises of a Government Department (other than the police force) Coroner via the Commissioner of Police
Any person in charge of a premises of the police force Coroner
The head of any department of the Government which receives a statutory notice in respect of any reportable death Coroner
Any police officer Coroner
The Registrar of Births and Deaths Coroner
Any registered medical practitioner seeking the consent of a coroner under Medical (Therapy, Education and Research) Ordinance in relation to the body of the deceased Coroner

Appendix III - Examples of Findings which may be made by the Coroner or the Jury

Finding Example
Natural causes An illness such as cancer or a heart attack
Occupational disease A disease arising from an occupation, e.g. asbestosis
Dependence on drugs / non-dependent abuse of drugs An overdose of narcotic drugs or other medication
Want of attention at birth Death as a result of insufficient care being given to a child at birth
Suicide Jumping from high rise building
Attempted / self-induced abortion Death resulting from an abortion or an attempt to abort a child
Accident Death resulting from an unexpected or untoward event, e.g. a traffic accident or a fall at work
Misadventure Where an act that is lawful but that has an unexpected consequence has caused the death
Lawful killing Death as a result of police use of firearms to prevent injury to a person or self defence
Unlawful killing Murder or manslaughter
Stillbirth The death of a foetus prior to birth
Open verdict This finding is made if the evidence is not sufficient for any other finding to be made

Appendix IV - Workflow Chart

Coroner's Court Workflow Chart