Holding a Coroner’s Inquiry for Deaths in Singapore

You may know someone who passed away recently. If the death was not due to natural causes, an autopsy may be conducted on the deceased as part of a coroner’s inquiry.

A coroner’s inquiry, also known as a coroner’s inquest, may be done to ascertain the identity of the deceased and the cause of the deceased’s death. This article will provide a general guide to coroner’s inquiries in Singapore.

It will cover:

• What is a coroner’s inquiry
• In which situations might a coroner’s inquiry be held in Singapore
• The process of holding a coroner’s inquiry after a death
• What can you do as a family member of a deceased person who may have died from having an offence committed against him/her
• Whether a coroner’s inquiry can be re-opened

What is a Coroner’s Inquiry? 

A coroner’s inquiry is an inquiry carried out by a coroner into the circumstances leading to a person’s death. The purpose of a coroner’s inquiry is to determine the identity of the deceased and how, when and where the deceased died. It is not intended to find fault in terms of identifying who may be liable for criminal, civil or disciplinary sanctions for causing the death.

If the death had been due to natural causes, a coroner’s inquiry is unnecessary. The coroner may then issue an order for the body to be released. However, there are instances where it is mandatory to conduct an inquiry, which will be explained below. The investigation into the circumstances of a deceased’s death will be done by a coroner of the Coroner’s Court with the aid of the police.

The coroner is a judge of the State Courts and the Coroner’s Court deals with cases that are classified by the police as coroner’s cases. If necessary, a State Counsel from the Civil Division of the Attorney-General’s Chambers (AGC) may be assigned to the coroner for the inquiry and, if so, will work closely with the Investigating Officer to present evidence at the inquiry.

In Which Situations Might a Coroner’s Inquiry be Held in Singapore?

In Singapore, the Coroners Act sets out when holding a coroner’s inquiry is mandatory. A coroner must hold an inquiry into deaths that occurred in Singapore where:

• A person dies while in police custody;
• The death was the result of lawful execution of a death sentence (to determine whether the sentence of death was duly carried out);
• The public prosecutor is satisfied that an inquiry is necessary or desirable; or
• The death occurred in any of the situations set out in the Third Schedule of the Coroners Act, unless the coroner is satisfied that the death was due to natural causes.

Some examples under the Third Schedule of when an inquiry must be held are when:

• The deceased’s identity is unknown
• The death occurred due to road traffic and industrial accidents (to ascertain the medical cause of death and circumstances leading to it)
• The death was caused or suspected to have been caused by an unlawful act or omission
• The manner or cause of the death is unknown (even where the deceased appears to have died of natural causes)
• The death occurred under suspicious circumstances

For instance, a coroner’s inquiry was conducted in the case of a construction firm director who died from a worksite fall. An inquiry was also carried out over the death of a 5-year-old girl, who drowned in a condominium pool after being left alone, to determine how she came by her tragic death.

In deciding whether to hold an inquiry, a coroner may take into consideration factors such as:

• For a death that appears to have been unnatural or violent, whether it appears to have been due to the action or inaction of any other person.
• The extent to which the drawing of attention to how the death occurred may be likely to reduce the occurrence of other deaths in similar circumstances.
• The desire of any immediate family member of the deceased that an inquiry should be conducted.
• Whether the death occurred outside Singapore, or was caused by matters arising outside Singapore (as the coroner only has jurisdiction over deaths or causes of death occurring in Singapore).
• Whether an inquiry or investigation into the death has been or will be conducted by a coroner or a corresponding authority of a foreign country.

The Process of Holding a Coroner’s Inquiry After a Death

Reporting of the death 

Under the Coroners Act, any person who becomes aware of a death that is a “reportable death” must report the death to a police officer. This should be done as soon as possible.

The obligation to report could fall on a passer-by or family member of the deceased who had noticed the reportable death, a person who had official custody of the deceased, or a police officer. Such persons are known as the informant. Situations constituting reportable deaths are similar to those where an inquiry must be held as stated above.

Investigations 

The police are obliged to investigate reportable deaths. When the police receive information of a reportable death from an informant, they will investigate the circumstances leading to the death and report their findings to the coroner.

Upon receiving information about the death, the coroner will, as soon as possible, make a preliminary investigation of the death to determine if an autopsy is necessary. The coroner will also view the body if it is practicable to do so.

However, recent amendments to the law have been proposed for the viewing of the body to be discretionary instead of mandatory. This is because there are already measures in place to ensure the correct identification of the deceased’s body, such as the tagging of the body with the deceased’s particulars at the scene and the mortuary. The Investigating Officer will also verify the accuracy of a Body Identification Form (containing the deceased’s particulars and photograph), and sign the form before sending it to the coroner.

The coroner or the public prosecutor may then direct a forensic pathologist to investigate the cause and circumstances into the death. If so, the pathologist may advise the coroner on whether to proceed with the autopsy, and then carry out examinations on the deceased’s body once the autopsy is authorised.

Autopsy 

The pathologist will provide the police and public prosecutor with regular updates on the progress of his investigations and findings. Once the autopsy is completed, the findings of the autopsy become part of the evidence adduced at the coroner’s inquiry.

The informant of the deceased’s death, the deceased’s spouse and children (aged 18 years and above) and the parents of the deceased can apply for the autopsy reports.

Open court hearing 

Before the coroner’s inquiry hearing, the coroner will conduct a pre-inquiry review called a Coroner’s Mention. This will be to settle any initial legal and administrative matters relating to the coroner’s inquiry so it can be expedited.

The coroner’s inquiry will then be held in open court unless the coroner has sufficient reasons not to do so. If so, these reasons must be reported to the public prosecutor. The coroner may also appoint up to 2 assessors skilled and experienced in the subject matter of the inquiry to advise him/her at the hearing.

The public prosecutor will then assist the coroner by presenting evidence gathered during previous investigations in the matter. Such evidence includes:

• The Investigation Report by the Investigating Officer;
• Documentary evidence such as the autopsy report and toxicology report of the deceased;
• Conditioned statements of the relevant witnesses; and 
• The report (if any) of expert witnesses, e.g. a medical opinion on a possible cause of death.

The coroner may conduct the inquiry in any manner he reasonably thinks fit. This means he is not bound by the rules of evidence and can admit any evidence he thinks is necessary. The coroner may also require a witness to give evidence in person if necessary. Any person may examine (i.e. ask questions to) such a witness with the coroner’s permission.

Properly interested persons may attend the hearing and examine witnesses. Such persons include:

• The spouse or next-of-kin of the deceased; and
• The personal representative of the deceased; or
• Any person who, in the coroner’s opinion, has an interest in the inquiry and should be allowed to attend.

Other parties who may attend the hearing also include representatives from the Embassy of the deceased’s country of birth or domicile (if the deceased is a foreigner), and lawyers acting on behalf of an interested third-party, such as a hospital or an insurance company.

Recording of findings 

At the end of the coroner’s inquiry, the coroner will record his findings as to the identity of the deceased and how, when and where the death of the deceased occurred. This would be recorded in the Coroner’s Certificate. The coroner may make findings that the death occurred by “suicide”, “misadventure”, or any other cause. For example, the case of the 5-year-old girl who drowned in the condominium pool, as mentioned above, was ruled as a tragic misadventure.

If a person is charged with any offence related to the death, the coroner will adjourn the inquiry only after criminal proceedings have ended.

After recording his findings, the coroner will forward a copy of the Coroner’s Certificate setting out the cause of death as found at the inquiry, to the Registrar-General of Births and Deaths and the public prosecutor.

Can the deceased’s family get a copy of the coroner’s certificate?

As the family member of the deceased, you may apply for the Coroner’s Certificate by submitting an application to the State Courts. You would have to include the details of the case, state your relationship with the deceased and specify that you are requesting for the Coroner’s Certificate. You may also consider attaching any supporting documents. Do note that there is a fee imposed, and the application is subject to the court’s approval.

What Can You Do as a Family Member of a Deceased Person Who May have Died From Having an Offence Committed Against Him/Her?

Can you insist that a coroner’s inquiry be conducted?

As a family member of a deceased who may have died from having an offence committed against him/her, you may want to know the cause of their death and seek “justice”. You may therefore insist on having an inquiry done.

However, where it is not mandatory to conduct an inquiry (as mentioned above), the decision on whether to hold an inquiry lies with the coroner. The coroner is not legally obliged to hold an inquiry if he is satisfied that the inquiry is unnecessary. This could be because the coroner finds that either the death was due to natural causes, or there is no public interest in holding an inquiry.

Nevertheless, in deciding whether to conduct an inquiry, a coroner will consider the desire of any member of the immediate family of the deceased that an inquiry should be conducted. Should the coroner decide not to hold an inquiry, the reasons for such a decision will be reported to the public prosecutor.

Can you refuse the conducting of a coroner’s inquiry?

On the other hand, you may want some closure from the tragic death of your loved one. As a result, you may want to refuse to have a coroner’s inquiry held so that you can arrange for a funeral. However, while your objection may be taken into consideration, you cannot refuse to have an inquiry held in situations where an inquiry would be mandatory. 

If your concern is that you will not receive your loved one’s body if a coroner’s inquiry is conducted, be reassured that the coroner will order the release of the body for burial or cremation. This will be after the death has been reported to the coroner and he or she sees it fit to release the body, regardless of whether he or she considers an inquiry to be necessary. However, if an autopsy has been ordered on the body, then the coroner is allowed to release the body only after the autopsy has concluded.

Re-opening of Coroner’s Inquiries

Once a coroner has issued a report, this would be the conclusion of the inquiry. However, while uncommon, the coroner may re-open the inquiry. This may be where new evidence has been found or where more investigation into the circumstances of the death is required.

Where the public prosecutor thinks that further investigations are necessary, he/she may direct the coroner to re-open the inquiry and make further directions. If the body has been buried, the public prosecutor may direct that a body be exhumed if he views that it is necessary to do so for the inquiry.

For example, 8 inquiries were re-opened for further investigations after an investigation officer was found to have forged statements in fatal road accident cases. The forgery could have materially impacted the findings of the inquiries as the evidence initially presented might have been incomplete or inaccurate. As a result, further investigations had to be conducted. 

While the coroner may re-open an inquiry, do note that the coroner may come to the same result as the initial inquiry after doing so. In the forged statements case, the coroner re-affirmed his findings for 7 out of the 8 re-opened inquiries in November 2021, with the final case being adjourned pending further investigations.

Conversely, where no new matters are raised, then the coroner would be unlikely to re-open the inquiry. In the case of the death of a prison inmate while in his prison cell, the AGC had clarified that the coroner’s inquiry was not re-opened because it was not necessary to. This was because the cause and circumstances leading to the death had already been decided upon in the criminal proceedings of the prison officer responsible for the inmate’s death, and no new matters called for the inquiry to be re-opened. 

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The purpose of a coroner’s inquiry is to find out the identity of the deceased and how, when and where the deceased died.

As a family member of the deceased, you may want the deceased’s body to be released so that you can make funeral arrangements and find closure. Be reassured that regardless of whether a coroner’s inquiry is carried out, the coroner will release the body to you.

If the deceased had been a victim of an offence leading to his/her death, and you are their next-of-kin, you may want to consult a criminal defence lawyer. A criminal defence lawyer can represent you in court and prepare questions you can ask during the inquiry. The lawyer may also visit the scene of the incident leading to the deceased’s death and advise on possible claims after the inquiry has been carried out.

You may get in touch with experienced criminal defence lawyers in Singapore here.