16 Coroner’s Inquiries

Role of Coroner

History: The Office of the Coroner

- Mediaeval Office of the Crowner – tax collector
o Since 1194
o A Crowner in every county
o Murdrum – death tax
o Whoever has body can lay claim to estate!!!! – weird medieval law – king wld lay claim to it first
o A tax gatherer
o “To protect the peace & dignity of the kingdom”
o Jurisdiction over Treasure Trove & Deaths – stll the case in UK
o In sg coroner no such juris

- Fiscal Role diminished & Investigative Functions changed with time

- Coroner’s Act 1887

- Circumstances and the actual medical causes of sudden, violent and unnatural deaths for the benefit of the
community as a whole.

- English Coroners retain jurisdiction over treasure trove

- Singapore – functions set out in Part VIII, Chapter XXX of the Criminal Procedure Code, Cap. 68

Role of the Coroner: Judicial Function

• Forensic pathologist does the medical examination – NOT the coroner
• CPC: Part VIII Special Proceedings Chapter XXX -- Inquiries of Deaths
– Section 284 CPC: “At every inquiry the Coroner shall inquire
 when, where, how and after what manner the deceased came by his death and
 also whether any person is criminally concerned in the cause of the death.”

Inquiries to be made by Coroner.

284. At every inquiry the Coroner shall inquire when, where, how and after what manner the deceased came
by his death and also whether any person is criminally concerned in the cause of the death.

- In Australia and in many other jurisdictions, the entire element of criminality is removed, but not in
Singapore.
• : - judicial determination
– but also has investigative fn
– ie both investigating and judicial fn (similar to civil area)

Role of the coroner investigative function

• s. 273(2) “As soon as possible after the officer has seen the dead body or started his investigation he shall
notify a Coroner …”
• s. 273(4) “A police officer investigating the circumstances.. shall from time to time furnish that Coroner
with any particulars concerning the death…”
- Investigative – Section 273(2) and Section 273(4) of the CPC.

Duty of police on receiving information.

273. —(2) As soon as possible after that officer has seen the dead body or started his investigation he shall
notify a Coroner stating any particulars concerning the cause of death which have come to his knowledge, and
giving his opinion as to whether the death was due to any unlawful act or omission or not.
 (4) A police officer investigating the circumstances connected with any death, which has been reported to a
Coroner under this section, shall from time to time furnish that Coroner with any further particulars
concerning the death which may subsequently come to his knowledge, together with the name of any person
who has been arrested and charged in connection with the death.

• The Coroner shall then give the police officer directions.

Now
• Not all cases of death are Coroner’s cases
• Fact finding office – must hold inquiry in certain circumstances
i. Where death is sudden / unnatural (Section 273(1))
ii. Where death caused by violence (Section 273(1))
iii. Where cause of death is unknown (Section 273(1))
iv. Where person dies in custody (Section 277)
v. Cases involving judicial hanging (Section 277)

Duty of police on receiving information.

273. —(1) On information being given to a police officer of the death of any person or that the dead body of a
person has been found and that there is reason to suspect that the person came by his death in a sudden or
unnatural manner or by violence, or if the manner in which the person came by his death is unknown, that
officer or some other police officer shall at once go to the spot where the body is lying or the death is believed
to have occurred and use his best endeavours to discover the cause of the death of the deceased and may arrest
any person whom he reasonably suspects of having caused the death.

Inquiry in case of person dying in institution or suffering capital punishment.

277. An inquiry shall be held in every case of the death of a person detained in an institution or of a person
who suffers capital punishment.

Jurisdiction

- The Coroner has jurisdiction over every dead body within the territory of Singapore where there is
reason to suspect that the death occurred in a sudden or unnatural manner or if the cause of death is
unknown.
• Ie if died somewhere but broght into sg, may have juris
• Sg no auth on this eng cases say so
• When any corpse is found in respect of which the cause of death is unknown or whose death has
been caused unnaturally, that corpse cannot be removed without the Coroner’s authority.
• The Coroner will invariably order a post mortem (although he has a discretion not to order a post
mortem) - see Section 282.
• The discovery of body parts or just pieces of tissue may pose problems. The criterion is whether
the parts found meant that a death had occurred. E.g. human skull as opposed to a femur (thigh
bone).

Post mortem examination of body.

282. —(1) In every case where it is expedient that the dead body of any person should be examined by a
medical officer, a Coroner shall forthwith issue his order to a medical officer to make or cause to be made a
post mortem examination of the body of the deceased person.
(2) A medical officer, if it is necessary in order to ascertain the cause of death or if instructed to do so by the
Coroner, shall extend the examination to the dissection of the body and an analysis of any portion of it and
may cause any portion of it to be transmitted to the Health Sciences Authority for any examination or analysis
to be carried out thereon.
(3) For the purpose of such post mortem examination, the Coroner may order the removal of the body to any
place within his jurisdiction which may be provided for that purpose.

 Death of persons under detention. Section 277 of the CPC.

 • Those under Detention: whether the death is natural or not, the Coroner has to investigate.
• Detention: Query: Who are those under detention?
i. Are all IMH Patients – not all are detainees – some are there voluntarily and not
by order of court
ii. Prisoners
iii. Destitutes in homes? (they are governed under the Destitute Persons Act).-
director of community devpt can order someone to be placed in welfare home – he
is considered detainee
• Reason – pple in thse places – there as ‘guest of state’ and state to look after you, and state has
interst to examine if you were ill treated etc

 Jurisdiction only over the dead.

• Does it include stillborns? – NO SEPARATE EXISTENCE – coroner may not have juris
• Test is whether sep existence fr mother’s womb
• Coroner only has jurisdiction over a body that is separate from the existence of the mother.

 The Coroner has no jurisdiction over members of Visiting Forces or persons with Diplomatic immunity.
[Visiting Forces Act; Diplomatic Privileges (C’wealth Countries and Republic of Ireland) Act; Consular
Conventions Act; Int’l Organisations (Immunity And Privileges) Act.]
– Visiting Forces Act
• NB Designated countries
– VF (Designation) Order 1963 – UK, Canada, Australia, NZ, India,
Pakistan, Sri Lanka, Ghana, British colony, protectorate, etc.
– 1969 - Malaysia; 1990 - USA; 2003 - France
– Diplomatic & Consular Relations Act 2005
– Int’l Organisations (Immunity And Privileges) Act. (eg fr UN or EU)

 Upon the direction of the Public Prosecutor, an inquiry could be held for a missing body. Section 279 of the
CPC.

Inquiry where body destroyed or irrecoverable.

279. When a Coroner has reason to believe that a death has occurred within his jurisdiction in such
circumstances that an inquiry ought to be held, and that owing to the destruction of the body by fire or
otherwise or to the fact that the body is lying in a place from which it cannot be recovered, an inquiry cannot
be held except by virtue of this section, he may report the facts to the Public Prosecutor and the Public
Prosecutor may, if he considers it desirable to do so, direct that an inquiry shall be held accordingly and the
law relating to Coroners and Coroners’ inquiries shall apply with such modifications as may be necessary in
consequence of the inquiry being held otherwise than on or after view of a body lying within the Coroner’s
jurisdiction.

• No body, then no jurisdiction.

• Need an order from Public prosecutor to get order.

• Reportable Deaths
• Unnatural Deaths
– homicide, suicide, Industrial Accident, Road Traffic Accident, asphyxia, drowning, neglect,
poisoning, electrocution, etc
• Therapeutic Event-related Deaths – (eg see doctor, and dies; dies in hospital)
• Persons in Statutory Care
• Brought In Dead cases where Cause Of Death is unknown
• Unidentified persons
 • Suspicious circumstances

The Coroner and the Public Prosecutor

- The office of the State Coroner is held by a Judge in the Subordinate Courts but is accountable to the Public
Prosecutor in the discharge of its statutory duties:
• Duty to report the facts to the PP in cases where there is no inquiry held e.g. natural causes [s 274(5)]

View of body by Coroner or burial without view.

274. —(5) In every case where a body is buried by order of a Coroner and no inquiry is held, the Coroner shall
report the facts to the Public Prosecutor with his reasons for not holding an inquiry and shall transmit all
reports and documents in his possession connected with the
matter.

- There can be situations when Coroner has reasonable suspicion that someone has died within jurisdiction
but body cannot be found. He can bring this to PP’s attention, which may direct that inquiry be carried out
under Section 279 of the CPC. (see above)
• PP may direct the Coroner to hold an inquiry or to order that a body be exhumed (s278)
• Not the same as Cemeteries Act

Power of Public Prosecutor to require inquiry to be held.

278. —(1) Where the dead body of any person has been found, the Public Prosecutor may require any
Coroner to hold an inquiry into the cause of, and the circumstances connected with, the death of that person,
and every Coroner so required may and shall hold the inquiry.
(2) The Public Prosecutor may also direct whether the body shall or shall not be exhumed and the Coroner
shall comply with the direction.

Inquiry where body destroyed or irrecoverable.

279. When a Coroner has reason to believe that a death has occurred within his jurisdiction in such
circumstances that an inquiry ought to be held, and that owing to the destruction of the body by fire or
otherwise or to the fact that the body is lying in a place from which it cannot be recovered, an inquiry cannot
be held except by virtue of this section, he may report the facts to the Public Prosecutor and the Public
Prosecutor may, if he considers it desirable to do so, direct that an inquiry shall be held accordingly and the
law relating to Coroners and Coroners’ inquiries shall apply with such modifications as may be necessary in
consequence of the inquiry being held otherwise than on or after view of a body lying within the Coroner’s
jurisdiction.

• PP may require the Coroner to reopen the inquiry and make further investigation (s281)

Power of Public Prosecutor to direct further investigation in certain cases.

281. —(1) Where the proceedings at any inquiry have been closed by a Coroner and it appears to the Public
Prosecutor that further investigation is necessary, the Public Prosecutor may require the Coroner to reopen the
inquiry and make further investigation and thereupon that Coroner may and shall reopen the inquiry and make
further investigation and thereafter proceed in the same manner as if the proceedings at the inquiry had not
been closed by the Coroner.
(2) This section shall not apply to any inquiry at which any finding of murder or culpable homicide not
amounting to murder or causing death by a rash or negligent act has been returned against any person named
in it.

• Coroner under duty to transmit records of inquiry to the PP (s299)

Depositions to be sent to Public Prosecutor.

299. Whenever any inquiry has been held, the Coroner shall forthwith transmit the depositions and records
 taken by him on the inquiry to the Public Prosecutor, together with a certificate to that effect duly filled up and
signed by him.

When a Case is referred to the Coroner

Referrals to the Coroner

– Any person aware of an unnatural death or death from unknown cause shall report to the police (s22)

Public to give information of certain matters.

22. —(b) of any sudden or unnatural death or death by violence or of any death under suspicious
circumstances or of the body of any person being found dead without its being known how that person came
by death,
shall, in the absence of reasonable excuse, the burden of proving which shall lie upon the person so aware,
forthwith give information to the officer in charge of the nearest police station or to a police officer of the
commission or intention or of the sudden, unnatural or violent death or death under suspicious circumstances
or of the finding of the dead body, as the case may be.

Investigation Stage
 When such a dead body is found or reported to the police, they have to proceed to the scene to conduct
investigations.
 In cases of suspected murder, the Coroner would also be informed and attend at scene before the body can
be removed. Cannot move body without coroenr’s permission!!!
 Otherwise, viewing of the body as required under the CPC is done at the mortuary on the following
day. The Coroner will then give directions to the Police.
 Where no foul play is suspected, the body will be removed to the mortuary for proper identification and
post-mortem examination.
 Everyday all dead bodies found will be sent to mortuary, one of magis of sub courts wil be there –
next of kin then brought in to look at body and identify body. Verify.
 Cororner will decide whether to order autopsy
 The body will be viewed by the Field Coroner and identified by the IO and Next Of Kin.
 The Field Coroner, with input by forensic pathologist, will decide if an autopsy is required.
 There is no appeal
 Only way is to quash by way of judicial review – certioriori
 But everything is done very fast (autopsy at 8am) – so need ot run to HC when it opens at 9am and
file pprs, then call coroner and tell them to stop the autopsy
 Issue Order to Bury or Cremate

 After these prelim investigations are done, a brief report is furnished to the State Coroner (SC) at the
Coroner’s Court.
 SC will review the case together with autopsy report, if any, and decide on the need for further
investigations.
 SC will conduct mentions-in-chambers with investigating officers (IOs) and prepare the cases for hearing, if
required
 .

Post Mortem
a) Where unnatural death or cause not known, post mortem (PM) to be carried out
b) Where death appears to be peaceful and no doctor called to certify cause of death, PM need not be carried
out.
c) During PM, deceased’s body operated upon by pathologist to ascertain cause of death; blood, bile, vitreous
humour taken for toxicology analysis.
d) 3 possible results of PM
 Cause of death by unnatural means (e.g. by drowning, fall from height)
 Cause of death by natural means (cancer, stroke, heart attack, uncertifiable)
 Cause of death unascertained (especially when bodies highly decomposed)

Hints For Next Of Kin

- Contact Police ASAP
- Provide as much detail as possible to police
- Police may arrange police hearse to transport body to Mortuary (CFM), Block 9, SGH, Outram Road
- Contact undertaker
- Forward all relevant documents & evidence to police
• NRIC
• Medical Records, Cards, actual medicines & prescriptions, medical history
 Pathologist needs to look at medical records becase eg medicine may have been wrongly
prescribed
• Other useful facts & evidence
- Speed is essential
• Bodies should reach CFM by 6:00 for same day release
• Muslims – must be buried within 24 hrs – problem.

Coroner’s Inquiry Hearing

INQUIRIES
276 Holding of inquiry.
277 Inquiry in case of person dying in institution or suffering capital punishment.
278 Power of Public Prosecutor to require inquiry to be held.
279 Inquiry where body destroyed or irrecoverable.
280 Adjournment of inquiry in cases of murder, culpable homicide not amounting to murder, or causing death by
rash or negligent act, when any person has been charged before a court in connection with such death.
281 Power of Public Prosecutor to direct further investigation in certain cases.
282 Post mortem examination of body.
283 Medical report of examination.

PROCEDURE AT INQUIRIES
284 Inquiries to be made by Coroner.
285 Coroner may summon witnesses.
286 Evidence how recorded.
287 Powers of Coroner.
288 Right of accused person to be present.
289 Right of accused person to examine medical officer.
290 Statement of accused person.
291 Recording of finding of Coroner.
292 Prosecution by Coroner’s order.
293 Course when guilty party unknown.
294 Certificate of Commissioner of Police.
295 Adjournment of inquiries.
296 Inquiry may be held by Coroner other than the one who viewed the body.
297 Inquiry may be continued by Coroner other than the one commencing it.
299 Depositions to be sent to Public Prosecutor.

• Inquisitorial v Adversarial
 Supervisory and adjudicative roles
 Pre-discovery of evidence
 Complete control over witnesses and proceedings (for judges may consider tainting of proceedings
but here coroner has complete control)

 Note: There is no appeal against the decisions of the Coroner. The only way is to file a judicial appeal to
quash it.

• Relevant people at the hearing

 Coroner
 Assisting Officer (assists by presenting evidence and documents, though will be a DPP or PO (a
Senior Police Officer), not in prosecutorial role.
  Investigative Officer who will present a summary of investigations (usually called as the first
witness).
 Next-of-kin with/without counsel. They are strictly speaking, party to the proceedings.
 “Potential Defendant” with/without counsel -

• AO to lead evidence thru the IO and witnesses, if any has been called to attend

 Use
 of written statements (Section 371 of the CPC): conditioned statements may be used. Can be proseucted
under section 182 if false.
 Only evidence which would assist the court to establish the cause of death relevant
 Note family membes may want to ascertain – let them have peae of mind. They can also
be difficult to handle.depends on whether coroner allows.

 NOK may ask questions with permission of the Coroner. But NOK has no absolute right to cross-examine.

 Only Potential def and assisting officer can ask

 Only the potential Defendant have the absolute right to cross examine witnesses etc.
 if you represent the accused person you will be allowed to ask questions, because your client
is facing the risk of a possible charge at the close of the Coroner’s Inquiry
 Lawyers usu rep next of kin and potential def. if the latter, have right ot ask questions! Note.

- if you appear for the members of the family, you are usually not granted the right to cross-examine
o it is in the discretion of the Coroner whether he allows you or not
o reason is simple – members of the family may want to extend the inquiry into areas in which
the Coroner is not interested – personal family feuds and so on

 Counsels on watching brief for witnesses or interested bodies

.
- the third category of client is the insurance company
- you may appear in the coroner’s court on a watching brief for an insurance company looking after its
interests

 Note: - But normally they will try not to call witnesses because of the nature of the death.

General characteristics of CI
o Coroner’s Inquiries are inquisitorial and not adversarial hearings
o So hearsay evidence can come in (usu this is the most relevant evid)
o Coroner’s Inquiries are quasi-criminal in orientation
o The rules of evidence not strictly applied. This is because it is not a prosecution. Therefore, hearsay
evidence can be used because it is an inquiry and not a trial.
o The Coroner’s Inquiry is concerned with how the death was caused
o The Coroner relies on the police to carry out the investigations

o The Coroner is a judicial officer and not medically-trained and is assisted by the forensic pathologist on the
medical aspects.

o No Coroner’s Inquiry if a person has been charged for causing the death
o The Coroner exists to account for sudden, unnatural or unknown causes of death
• The role of a coroner is very limited. At the end of the prosecution evidence, the Coroner shall say to the
accused these words or words to the like effect: -

Section 290
 Statement of accused person.
290. —(1) After the evidence on behalf of the prosecution is closed the Coroner in the event of any accused
person being present shall say to him these words or words to the like effect:
“Having heard the evidence do you wish to say anything? You are not obliged to say anything unless you
desire to do so; but whatever you do say will be taken down in writing and may be given in evidence in
subsequent proceedings”.
(2) The statement of the Coroner to the accused or the effect of it and any statement made by the accused or
evidence given by him shall be recorded by the Coroner as part of the depositions and shall be transmitted with
them as hereinafter mentioned.

• Whether you would advise your client to remain silent or to give evidence is a matter for you to decide, but
usually at the Coroner’s inquiry, the only concern is possible insurance claims.
• But note that if you are acting for an accused person, his decision not to give evidence may prompt the
Coroner into issuing a warrant for his arrest on a charge of causing death by a negligent act.
• there may be a conflict of interest
• from the point of view of the insurance company, it may not be desirable to give evidence, but from the
point of view of the accused it may be desirable
• if you find yourself in a position of conflict of interest like that, you may have some problems

Common verdicts

• Death was due to a natural cause

 General rule is no CI under detention cases. See Section 277 of the CPC. See above.

• Suicide
- Before the Coroner can make a finding of suicide, there must be sufficient evidence of the deceased’s
intention to kill herself. This must be beyond a reasonable doubt.
- Prev, suicide – insurance claims invalid
- Now, with amendments to Isurance Act, suicide does not invalidate debts

R v Cardiff City Coroner ex parte Thomas [1970] 3 All ER 469

 To find a verdict of suicide, there must be satisfactory evidence that the deceased had an intention to kill
himself
 Facts:
 At the inquest of the deceased, evidence was given that:
(a) the body was discovered in a river;
(b) the condition of the body was such that it was impossible to ascertain the cause of death; and
(c) the deceased had a background of illness (old war wounds, nervous eczema, a wart on the foot
which caused considerable pain, difficulty in sleeping, etc), though the pain was not
particularly bad at the time before his death
 The coroner recorded a verdict of suicide.
 The applicant, the deceased's widow, applied for an order of certiorari to quash the verdict on the
ground of lack of evidence of suicidal intent and for a fresh inquest to be ordered.
- Held, application granted:
 Satisfactory evidence of suicidal intent is always necessary to establish suicide as the cause of death.
 The mere fact that accident was not established does not mean that suicide was established.
 Suicide is voluntarily doing an act for the purpose of destroying one's own life whilst one is
conscious of what one is doing. ∴To arrive at a verdict of suicide, there must be evidence
that the deceased intended the consequences of the act.
- Comments: Voluntarily doing an act for the purpose of destroying one’s own life is conscious of what one
is doing, must have evidence that intention was to take own life.
 E.g. If there are numerous dead bodies found at the void deck, unless there is a suicide note, no
one truly knows. In the absence of any such evidence, Court will return an open verdict instead
of one of suicide. Evidence could include suicide notes or confessions to NOK. May even have
eyewitness.
• Misadventure
 Accidental, fault of deceased, acceptable medical complications, act of God e.g. strike by
lightning.
 No human control

• Negligent Act – Note: Burden of Proof is on a criminal scale.

o The criminal standard of negligence (in a verdict of death by a negligent act) is the same as
the civil standard of negligence
o Lim Poh Eng v PP (1999).
 Facts: The appellant, a practitioner of traditional Chinese medicine, was charged
with s 338 PC for causing grievous hurt by negligent act endangering human life. A
patient’s rectum had to be removed after a prescribed course of colonic washouts.
 The appellant was convicted. One of the grounds of his appeal was that the degree of
negligence required in criminal cases should be higher than that of civil cases. He
argued that the standard of negligence in criminal cases should be an intermediate
standard of negligence, lower than the standard of gross negligence for the common
law offence of manslaughter, but higher than the civil standard of negligence
 Held:
 Previous decisions of the High Court have settled that the degree of negligence in
criminal cases is the same as that required in civil cases.
 But it is open to the High Court in this appeal to review the law on the standard of
negligence for criminal cases.
 On review, the standard of negligence in criminal cases should be the civil
standard of negligence.
 Although there is a need to maintain a distinction between civil liability and criminal
liability, it is not necessary to have an intermediate standard of negligence in order to
maintain that distinction. Even without a different standard of negligence, there are
still two essential differences between a tort in negligence and criminal liability
which involves negligence:
a. In a crime which involves negligence, the breach of the civil
standard of negligence has to be proved beyond reasonable doubt, as
opposed to a balance of probabilities.
b. In a crime which involves negligence, negligence is not the sole
criteria of liability. There are additional elements which have to be
proved, and proved beyond reasonable doubt.
 It would be difficult to apply an intermediate standard of negligence in practice:
• There is a dearth of authority to explain what the intermediate standard of
negligence would be in different situations.
• Even within the law of tort, the civil standard varies in accordance with the
circumstances. An intermediate standard of negligence would be too
elusive a concept to be workable
o Comments: In contrast to road traffic cases, which were mostly caused by a momentary
lapse, the negligence in this case occurred over a period of time in the context of a patient-
doctor relationship. The offence was a serious one as the appellant prescribed colon cleansing
without proper training and took extremely poor care of H.

• Murder (e.g. by person(s) unknown) (to find ‘known’ – shld be finding of court. Position in sg unclear)
• 2 scenarios when such a verdict returned.
a) Suspects arrested and charged in court. In such cases, at the end of criminal trial,
Coroner will be informed of the result and he may choose to close the case under
Section 280(4) of the CPC.
b) Suspects are still at large. In such cases, the normal practice is for the police to wait for
some time to see if the suspects can be apprehended before proceeding with CI. If
Coroner is satisfied, will return with the verdict of murder.

• Justifiable Homicide
  Right of private defence as provided in Section 96-106 Penal Code
 This includes law enforcement officers killing with authorised firearms.

• Death by Judicial Hanging.

• Open Verdict. This is where evidence does not disclose manner or circumstances when death came about,
includes situations where evidence is equivocal. See example given above.
o So can still sue
o Relevcant in many insurance claims

Section 280 of the CPC: stay

• Normally when there is a prosecution for murder or causing death by a rash or negligent act, the Inquiry
proceeding is stayed.
o To avoid duplication of proceedings when someone has been charged.
o To avoid inconsistent findings.
o Prosecution takes precedence.
• Duty of Magistrate, District Judge, Registrar of Supreme Court to inform Coroner of result of proceedings.
• Duty of the Coroner is to determine whether any person is criminally concerned in the death.
• Discretion whether to resume inquiry.

Adjournment of inquiry in cases of murder, culpable homicide not amounting to murder, or causing
death by rash or negligent act, when any person has been charged before a court in connection with
such death.
280. —(1) If on an inquiry touching the death of any person a Coroner is informed that some person has
been charged before a District Judge or Magistrate with the murder, culpable homicide not amounting to
murder, or causing death by a rash or negligent act, of the deceased, he shall, in the absence of reason to
the contrary, adjourn the inquiry until after the conclusion of the criminal proceedings.

(2) After the conclusion of the criminal proceedings the Coroner may, subject as hereinafter provided,
resume the adjourned inquiry if he is of opinion that there is sufficient cause to do so:
Provided that, if in the course of the criminal proceedings any person has been committed for trial before the
High Court or tried by a District Judge, then upon the resumed inquiry no inquisition shall charge that person
with an offence of which he could have been convicted at the trial or contain any finding which is inconsistent
with the result of those proceedings.

(3) Where a Coroner resumes an inquiry, which has been adjourned in accordance with this section, he shall
continue with the inquiry from the stage at which it was adjourned.

(4) If, having regard to the result of the criminal proceedings, the Coroner decides not to resume the inquiry he
shall endorse his record accordingly and also the certificate required under section 299 and shall transmit the
depositions and records to the Public Prosecutor together with the certificate duly filled up and signed by him
as required under section 299 in the case of a completed inquiry. He shall also send a copy of the certificate to
the Commissioner of Police.

(5) It shall be the duty of the District Judge or Magistrate before whom a person is charged with murder,
culpable homicide not amounting to murder or causing death by a rash or negligent act to inform the Coroner
who is responsible for holding an inquiry of the result of the criminal proceedings before him, and it shall be
the duty of the Registrar of the Supreme Court to inform the Coroner of the result of any proceedings before
the High Court or the Court of Criminal Appeal.
Form 44. Forms 45 and 46.
(6) For the purpose of this section, “criminal proceedings” means the proceedings before the Magistrate at a
preliminary inquiry, and before any court by which the accused person is tried or before which an appeal from
the decision of that court is heard, and criminal proceedings shall not be deemed to be concluded until no
further appeal or action can be made in the course of them.

Role of lawyers and State Counsel in Coroner’s Inquiries

• Generally to assist the court
– provide useful info; witnesses
– do so early on rather than raise it at CI
• NOK’s representative
– help them understand what CI is
– ask relevant questions
• PD’s representative
– PD’s rights and obligations
• The CI is NOT a fishing expedition or rehearsal for a Prosecution or civil litigation
o Watching brief for witnesses and interested persons
 Strictly no locus standi at CI
 Court may allow participation
o DPP
a) Exercise prosecutorial discretion
b) Assist in presentation of evidence
c) Recommend subsequent actions, if any.

Possible reforms –
- A Coroner at an inquiry may make a recommendation designed -
o to prevent the recurrence of fatalities similar to that in respect of which the inquiry is being held;
o to prevent other hazards to life disclosed by the evidence at the inquiry
o to bring to the attention of a person who may have the power to take appropriate action any
deficiencies in a system or method of work which are disclosed by the evidence at the inquiry and
which are of public concern.

- There are 3 kinds of lawyers: -

i. Acting for the NOK: usually not granted the right to cross-examine. It is at the discretion of the
coroner whether he allows you to or not.
ii. Acting for the potential Defendant – there to protect interests of potential Defendant (civil
proceedings may or may not follow from the inquiry): You as counsel will be allowed to ask
questions because your client is facing the risk of a possible charge at the close of the Coroner’s
Inquiry.

iii. Acting for third parties (e.g. Insurance companies)

- The lawyers who appear must convince Coroner that he is helping with inquiries; his questions should aim
at establishing the facts.

Organ Transplantation & The Coroner

• Human Organ Transplant Act – opt out
• Medical Therapy (Education & Research) Act – opt in

HOTA
• Coroner’s role only arises in cadaveric transplantation
• In cases where Coroner has jurisdiction (i.e. all unnatural deaths)
• No authorisation for removal without Coronial consent - s 6(1)
Coroner’s consent.
6. —(1) If the designated officer of the hospital has reason to believe that the circumstances applicable to the
death of the person are such that the Coroner has jurisdiction to hold an inquest into the manner and cause of
death of the person, the designated officer shall not authorise the removal of any organ from the body of
the deceased person unless the Coroner has given his consent to the removal.

• Consent may be subject to conditions – s 6(2)

 (2) The consent by the Coroner under this section may be expressed to be subject to such conditions as are
specified in the consent.

• Consent may be oral, followed in writing – s 6(3)

(3) The consent may be given orally by the Coroner, and if so given shall be confirmed in writing.

• (cf s 16(1)(b), MTERA)

Removal and use of body to be lawful.
16. —(1) Subject to subsection (2), the removal and use of any part of a body in accordance with section 3 or
4, as the case may be, or the post-mortem examination of a body in accordance with the provisions of Part III,
shall be lawful.
(2) No such removal or post-mortem examination shall be effected except —
(a) by a registered medical practitioner, who shall have satisfied himself that the death of the deceased person
has been determined and certified in accordance with section 2A of the Interpretation Act (Cap. 1); or
(b) with the written consent of the Coroner in a case where an inquiry is to be held in respect of the death of
any person.

Application to:
- Kidney, heart, liver & corneas – 1st Sch.
- Death in hospital – s 5(1)

Authorities may remove organ after death.

5. —(1) The designated officer of a hospital may, subject to and in accordance with this section, authorise, in
writing, the removal of any organ from the body of a person who has died in the hospital for the purpose of the
transplantation of the organ to the body of a living person.

• S 5(2):
o No removal if person has objected
o Must be citizen or PR
o Must be above 21 (save with parental consent), or below 60
o No removal if donor of unsound mind, save with parental/guardian’s consent
o No removal for Muslims

2) No authority shall be given under subsection (1) for the removal of the organ from the body of any deceased
person —
(a) who has during his lifetime registered his objection with the Director to the removal of the organ from his
body after his death;
(b) Deleted by Act 1/2004, wef 01/07/2004.
(c) who is neither a citizen nor a permanent resident of Singapore;
(d) who is below 21 years of age unless the parent or guardian has consented to such removal;
(e) who is above 60 years of age;
(f) whom the designated officer, after making such inquiries as are reasonable in the circumstances, has reason
to believe was not of sound mind, unless the parent or guardian has consented to such removal; or
(g) who is a Muslim.

MTERA
- All deaths other than hospital deaths covered by MTERA, incl. Suicides & judicial hanging
- Any person of sound mind above 18 may donate
- All parts can be removed
- Written consent of Coroner required in CI cases – s 16(2)(b), MTERA
o Even where donor consent given
o No need for consent if not a CI case

Removal and use of body to be lawful.

16. (2) No such removal or post-mortem examination shall be effected except —
(a) by a registered medical practitioner, who shall have satisfied himself that the death of the deceased person
has been determined and certified in accordance with section 2A of the Interpretation Act (Cap. 1); or
(b) with the written consent of the Coroner in a case where an inquiry is to be held in respect of the death of
any person.