Scope of inquiry Minute October 2021 plus appendices [pdf, 720 KB]
...look into any underlying causes of death, including failures of systems or procedures at any level, but the investigation should remain an inquiry about the particular death. Deaths implicating State actors in arguable breaches of protected human rights [46] As noted earlier, where a coronial inquiry follows a Police investigation and criminal prosecution, a Coroner’s decision on scope will need to carefully factor the extent to which the cause and circumstances of death have b...