The report may contain recommendations to prevent future loss of life under similar circumstances. Coroner's Inquest A coroner's inquest is a quasi-judicial court proceeding. An inquest may be held as a way to ascertain facts relating to death. It can serve to formally focus community attention on and initiate community response to preventable deaths. An inquest is mandatory in all deaths that occur in police custody.
Coroners have the authority to summon a jury and subpoena witnesses.
The presiding coroner of an inquest has the same authority as a Supreme Court judge to preserve order and prevent abuse of the inquest process. The role of the coroner is to organize, control and adjudicate. The coroner also determines which parties will have standing at the inquest, applies the appropriate rules of evidence and ensures that the rights of witnesses are protected. A coroner's inquiry or investigation is a serious matter and should not be taken lightly. The coroner is responsible for instructing jury members as to their responsibility under the Coroners Act , ensuring that the jury maintains the goal of fact finding, not fault finding.