PRACTICE DIRECTION - 39
CORONIAL PROCEEDINGS
I. Introduction
1. This Practice Direction governs the practices to be adopted in the Coroner’s Court.
2. An important underlying objective of the Coroner’s Court is to ensure investigations into relevant deaths are completed as quickly as possible. In achieving this objective, the Court will also take into account practical considerations and ensure that the investigations are thorough, addressing all relevant issues and interests of stakeholders. This Practice Direction aims to facilitate the Coroner’s Court in dealing with cases in an efficient, expeditious and timely manner while paying due regard to practical considerations by formulating timelines and timetables that are reasonably practicable.
3. In this Practice Direction,
“Coroner” has the same meaning as that provided in section 2 of the Coroners Ordinance (Cap. 504);
“Ordinance” means the Coroners Ordinance (Cap. 504);
“PIP” means a properly interested person as specified in section 2 and Schedule 2 of the Ordinance;
“Pathologist” refers to the pathologist who is ordered to perform the autopsy on the dead body concerned pursuant to section 6 of the Ordinance.
II. Case management
4. To promote consistency and enhance efficiency, case management and target timetables for death investigations and inquests are introduced to ensure speedy determination of all issues in coronial proceedings.
5. It is the responsibility of all PIPs, their legal representatives and those who are asked to assist the Coroner by providing relevant information and reports to meet the target timetable and any directions made by the Coroner with reasonable diligence. Where appropriate, directions hearings will be held to further these objectives.
A. Autopsies
6. In the event the Coroner orders an autopsy pursuant to section 6 of the Ordinance, the Pathologist shall within 3 months of the order provide to the Coroner the medical cause of death of the deceased together with the post mortem examination (autopsy) report.[1]
7. If further tests (including but not limited to toxicology, histology, microbiology and DNA tests) are required and it is anticipated that the test results will not be available within the prescribed period, the Pathologist shall within 21 days from the expiry of the 3-month period:
(1) notify the Coroner of the delay and the reasons for the delay; and
(2) provide a “provisional cause of death” or “interim post mortem notes” relating to the deceased’s death, if the Pathologist is in a position to do so, to assist the Coroner to consider at an earlier stage whether it is necessary to carry out a death investigation.
B. Death investigation reports
8. The Coroner may decide to investigate into any reportable death or any death which has come to his/her attention pursuant to section 9 of the Ordinance.
9. The police, if instructed by the Coroner to carry out a death investigation, shall submit the death investigation report within the deadline set by the Coroner in accordance with the Ordinance and this Practice Direction.
10. The death investigation report (Form 16) shall contain, inter alia, the following:
(1) witness statements, medical reports, autopsy reports, expert reports (if applicable);
(2) Investigation Officer’s remarks and recommendations;
(3) comments and recommendations of the supervisor of the Investigation Officer; and
(4) Coroner’s Officer’s remarks and recommendations.
11. The Coroner may direct the police officer or relevant person in charge to submit an interim death investigation report (“the Interim Report”) so as to be apprised of the progress of the investigation. The Interim Report shall be submitted within 3 months from the issuance of the instructions, and shall include the following:
(1) background of the death;
(2) status of the investigation;
(3) matters/issues arising from the investigation;
(4) post mortem examination report (if available);
(5) list of witnesses/potential witnesses who have been identified;
(6) outstanding matters which need to be completed; and
(7) an estimated time for the completion of the investigation report.
12. Upon receipt of the Interim Report, the Coroner will, if appropriate, give directions to facilitate the investigation, including but not limited to setting out various timetables for the completion of the investigation work. The direction by the Coroner for an Interim Report and/or the provision of an Interim Report does not in any way absolve a party from the responsibility to comply with the deadline imposed by the Coroner for the completion of the full death investigation report.
C. Deaths involving medico-legal issues
13. The Coroner when giving instructions to investigate into a death shall inform the police in writing whether the death to be investigated involves medico-legal issues.
14. The provisions in this part shall apply if the Coroner informs the police that the death involves medico-legal issues.
15. The police shall:
15.1 notify the medical practitioner responsible for the deceased’s medical care immediately before his/her death to furnish a medical report to the Coroner; and
15.2 notify the medical practitioners who had been providing care to the deceased at the time of death and/or had been treating the deceased during the 3 years before the death (such as the treating general practitioner, dentist, physiotherapist, Chinese medicine practitioner, etc.) to each furnish a witness statement or a medical report on the care and/or treatment provided to the deceased as well as on the deceased’s medical conditions.
16. During the course of an investigation, the Coroner may, upon being satisfied that additional statements and/or medical reports from medical practitioners on the treatment and/or care which had been provided to the deceased beyond 3 years before death are required, instruct the police to make the relevant request.
17. For the purposes of paragraphs 15 and 16,
17.1 if the medical practitioners are in the private sector, the police shall notify them directly.
17.2 if the medical practitioners are in the public sector under the Hospital Authority, the police shall notify the Medical Record Office (“MRO”) of the relevant hospital to arrange for the appropriate medical practitioners to furnish medical reports to the Coroner.
17.3 in either case, the medical practitioner shall furnish the witness statement or medical report within 3 months after being informed by the police. The Coroner may, upon an application made through the police, extend the time for furnishing the statement or report if good cause is shown.
18. All PIPs and medical practitioners who have been requested to provide information by the police under the instruction of the Coroner have a duty to assist in the completion of a death investigation involving straightforward and non-complex medico-legal issues within a target of 15 months after the Coroner has ordered the police to conduct the death investigation.
D. Deaths not involving medico-legal issues
19. The provisions in this part shall apply if the Coroner informs the police that the death does not involve medico-legal issues.
20. If the deceased was hospitalised before death, the police shall notify the medical practitioner responsible for the deceased’s medical care immediately before the death to furnish a medical report to the Coroner.
21. If either (1) the deceased was not hospitalised before death or (2) the deceased’s death was certified in the Accident and Emergency Department, paragraphs 15.2 and 16 in Part C shall apply.
22. For the purposes of paragraphs 20 and 21, paragraph 17 in Part C shall apply.
23. All PIPs and medical practitioners who have been requested to provide information by the police under the instruction of the Coroner have a duty to assist in the completion of a death investigation not involving medico-legal issues within a target of 9 months after the Coroner has ordered the police to conduct the death investigation.
E. Deaths involving investigations by a government department/ organisation or a prosecuting authority other than the police
24. In a case where a government department/organisation or a prosecuting authority other than the police is required by law to conduct an investigation (e.g. for a death resulting from an accident or injury at a workplace, a death of a seafarer, a death resulting from a fire and/or an explosion, etc.) and the Coroner has ordered a death investigation, the relevant department/organisation or prosecuting authority shall within 12 months of the date of death make available to the Coroner through the police a copy of the report setting out the results of the investigation to enable the police to complete the full death investigation report.
25. Other than in the situations set out in sections 33(2), 35(1) and 36 of the Ordinance, the mere anticipation of criminal proceedings is not a valid reason to withhold disclosure of the investigation report.
26. If for any reason a copy of the report cannot be made available within the 12-month period, the relevant department/organisation or prosecuting authority shall before the expiry of the prescribed period provide a written explanation to the Coroner detailing the circumstances leading to the delay and the estimated time for the completion of the investigation and/or supplying a copy of the report.
F. Deaths in official custody
27. This Part applies to cases of death of a person whilst in official custody where
(1) it appears that the cause of death of the deceased was natural;
(2) the cause and circumstances leading to the death are not in dispute;
(3) there is an absence of any allegation or complaint by PIPs in relation to the care and treatment provided to the deceased; and
(4) the Coroner is of the view that prevention of future deaths is not engaged.
28. The police under the instruction of the Coroner shall notify the medical practitioners responsible for the deceased’s medical care within 1 year before the death to furnish medical reports to the Coroner. Paragraph 17 in Part C shall apply.
29. In the event that medico-legal issues are also involved, the provisions in Part C shall apply.
30. The death investigation shall be completed within 9 months after the death.
31. Section III applies to an inquest of the death of a person whilst in official custody.
G. Notification of the progress of death investigations
32. If the Coroner has given instructions to investigate into the death of the deceased, and the investigation is not completed within 9 months of the date of the Interim Report or no decision on whether to hold a death inquest has been made within that period, the Coroner will, in appropriate cases, inform the next of kin of the progress of the death investigation (including the matters that are outstanding) every 3 months.
33. After the completion of a death investigation, if the Coroner decides not to hold an inquest into the death of the deceased, a written notification of the decision together with the reasons for it will be provided to the next of kin.
H. Directions hearings
34. A Directions Hearing may be held in chambers or in open court. All PIPs shall be notified of the place, time and date of the Directions Hearing.
35. The Coroner may hold a Directions Hearing where a person has failed to comply with a direction by the prescribed deadline (and no extension has been granted), and require the person or his/her representative to appear to explain the non-compliance.
36. A Directions Hearing may be held in any case and regardless of whether a death inquest will ultimately be conducted.
37. At the Directions Hearing, the Coroner may:
(1) grant a time extension to comply with directions if the same is warranted;
(2) issue consequential orders and directions where there has been wilful non-compliance with directions resulting in obstruction and delay to the discharge of the Coroner’s duty to investigate; and/or
(3) make any other orders and/or directions as deemed necessary and appropriate.
III. Death inquests
38. When the Coroner makes a decision to hold a death inquest pursuant to section 14 of the Ordinance, and the Coroner is minded to hold the death inquest without a jury, the Coroner will serve all PIPs with a form pursuant to section 28(2) of the Ordinance (known as “Form 10”) to inform them of that intention so that the PIPs will have an opportunity to make representations. It is ultimately the Coroner’s decision whether to hold the inquest with a jury after consideration of all relevant factors (including the PIPs’ representations on this matter, if any).
39. In all cases where the Coroner has made a decision to hold a death inquest (with or without a jury), all PIPs will be served with a written notice (“Notice of Inquest”) pursuant to section 28(1) of the Ordinance.
A. Listing of inquests
40. The Coroner shall decide which witnesses and doctors to call at the inquest hearing, and their respective witness statements and reports shall be included in the Coroner’s Bundle to be used at the inquest. Any PIP may, if he/she so wishes, within 14 days after the service of the Notice of Inquest (“the 14-day Period”) apply to the Coroner for a copy of the witness statements and reports (including expert reports) contained in the Coroner’s Bundle.
41. After the expiry of the 14-day Period, each of the PIPs shall within
35 days inform the Coroner in writing as to whether he/she is of the view the inquest is ready to be listed for hearing and whether he/she will call his/her own expert(s).[2] If a PIP is of the view that the inquest is not ready to be listed, he/she should give reasons in writing.
42. Where the Coroner has decided after consideration of all relevant factors (including the views of the PIPs) that the inquest is ready to be listed for hearing, the Coroner will proceed to list the inquest for hearing.
43. Subject to the provisions under the Ordinance and unless justified by the special circumstances of the case, an inquest that has been listed for hearing will not be vacated or adjourned.
B. Inquests into deaths in official custody
44. In accordance with section 15 of the Ordinance, inquest into the death of any person who dies whilst in official custody will be listed for hearing as soon as reasonably practicable.
C. Expert evidence
45. The Coroner may, if he/she considers it necessary, commission an independent expert witness to provide a written opinion report for a coronial investigation. The expert may be required to attend an inquest and give evidence on the expert opinion he/she has provided.
45.1 Any PIP may engage (an) expert(s) to comment on any issue that is relevant to the cause and circumstances leading to the death of the deceased.
45.2 If the Coroner decides to hold an inquest, a party may, if he/she so wishes, within 35 days after the expiry of the 14-day Period make a written request to the Coroner to have his/her expert(s) testify at the hearing. The Coroner may, upon application and for good cause shown, extend the time for making the request.
45.3 The request should contain a proposal on when the relevant expert report(s) is/are to be submitted to the Coroner.
45.4 The decision on whether to call any such expert(s) as witness(es) at the inquest shall rest with the Coroner.
46. Any late application to file expert evidence (in particular, any application made after the inquest hearing has been listed, resulting in a possible adjournment of the hearing) shall not be entertained save in exceptional circumstances.
47. Subject to any relevant law and Practice Direction 29 (where applicable), the Coroner may in appropriate cases permit an expert witness to be examined by way of a live audio-visual link.
IV. Commencement date
48. This Practice Direction shall come into effect on 2 June 2025.
Dated this 16th day of May 2025.
| (Andrew Cheung) | |
| Chief Justice |
[1] In cases where the Pathologist does not support waiver of an autopsy and the next of kin wishes to make representations against that recommendation before a Coroner, the mortuary/hospital shall arrange an appointment with the Coroner’s Court Registry on behalf of the next of kin, who will have an opportunity to make representations to the Coroner as soon as practicable.
[2] If the Coroner’s expert raises issues or makes recommendations concerning certain doctors/hospitals/institutions, the Coroner will direct the police to forward a copy of the expert’s report to the parties concerned for comments and/or consideration as to whether to engage their own expert(s) within the time frame set by the Coroner which will take into account the complexity of the issues involved. The inquest will not be listed before the expiry of the time frame set by the Coroner.