What public records and disclosures are likely to be released after a coroner completes its findings in Western Australia?
Executive summary
When a coronial investigation in Western Australia is finalised the public can expect a narrow set of formal outputs: findings in relation to reportable deaths, any public inquest documentation where a hearing was held, and occasional public recommendations about safety or administration; however many routine, non‑narrative findings are not published and archival records or detailed material (police reports, post‑mortems, internal referrals) are often subject to access limits or held only in archives [1] [2] [3].
1. What “findings” look like and whether they’re released
A coroner’s formal finding states the deceased’s identity, cause of death, the circumstances and the particulars needed to register the death, and findings made after a public inquest are generally able to be accessed by the public, but the Coroner’s Court emphasises that many findings — particularly brief, administrative or “non‑narrative” findings issued in chambers — are not published online and routine requests for release are often unsuccessful [1] [4].
2. Published inquest findings and online posting
When a matter proceeds to an inquest and a public hearing occurs, the Coroner’s Court does publish inquest findings and maintains a specific “Inquest Findings” page listing recent matters, which is the primary public channel for those outcomes [3] [5]; secondary commentary from legal practitioners notes that findings from coronial inquests are published on the Court’s website after inquests [6].
3. Recommendations, comments and public‑safety output
In a subset of cases coroners go beyond cause‑of‑death determinations and make comments or recommendations about public health, safety or the administration of justice — these recommendations are an explicit statutory function and are sometimes circulated publicly as part of the inquest material or the coroner’s published findings [2].
4. Referrals to prosecutors or police — disclosure limits
If evidence suggests an offence, coroners may refer matters to the Director of Public Prosecutions or to police, but statutory and judicial conventions limit coroners from framing findings that impute guilt or civil liability; whether the referral paperwork itself is publicly released is not clearly set out in public guidance and will depend on separate disclosure rules and prosecutorial practice [6] [7].
5. What is not routinely published: administrative findings and case files
A significant portion of coronial output — short administrative findings concluding investigations without a public hearing — is not routinely published online and can be hard to obtain by request, a situation the Court attributes partly to historical record‑keeping practices and the absence of a centralised system for older records [1] [8].
6. Medical and investigative records: post‑mortems, police reports and archives
Detailed investigative materials such as autopsy reports, police briefs and witness statements form part of coronial files and are preserved in various records series; some historical coronial files are available through the State Records Office or the State Library, but access to contemporary forensic or police material is restricted and subject to separate access regimes [9] [8].
7. Public summaries and sector publications
Health‑sector summaries and thematic reports drawn from coronial work are also published: for example, an annual health‑focused compendium called “From Death We Learn” provides summaries of health‑related coronial inquest findings and is publicly available, offering a way the system shares lessons without releasing every file [10].
8. Practical routes for journalists, families and researchers
The Coroner’s Court provides procedural information, operates a media liaison process and requires accreditation for court reporting; researchers seeking material should therefore expect to use the Court’s published findings page for inquests, pursue archival channels for older files, and be prepared for refusals or redactions where findings were made in chambers or material is sensitive [11] [5] [1].
Conclusion: predictable outputs, constrained transparency
In Western Australia the predictable public outputs after a coronial finding are published inquest findings and, where relevant, public recommendations and health‑sector summaries; much of the granular investigative material and non‑narrative findings remain off the public register, accessible only in narrow circumstances or via archival holdings, meaning transparency is strongest where a public inquest has been held and limited where deaths were concluded administratively [3] [2] [1].