represented by a (barrister or solicitor) and, either personally or by that person, to examine witnesses on matters relevant to the inquest - - ." Section 33 provides:- "Subject to this Act a Coroner is not bound to observe the rules of procedure and evidence applicable to proceedings before a court of law." Section 37 provides:- "(1) At the conclusion of an inquest, the Coroner shall record his findings in relation to - (a) the identity of the deceased person; (b) when and where the deceased person came to his death; and (c) the manner and cause of the death of the deceased person, and the particulars required by section 10(4) to be ascertained." 13. See the form of Inquisition at Form 16; this is the document which formally embodies the record of the findings. It may be noted here that the Act is silent on the question of adding riders to the findings, as is also the Coroners Act (NSW). The position is different in England. In the Coroners Rules 1953 (UK), Rule 27 provided:- "27. Neither the coroner nor the jury shall express any opinion on any matters other than those referred to in (Rule 26, which was in terms similar to s.37 of the Act). Provided that nothing in this Rule shall preclude the coroner or the jury from making a recommendation designed to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held." 14. It can be seen that the proviso contemplated that riders by way of recommendations of a particular type could be added publicly to the verdict. These riders of a public nature were abolished by the Coroners Rules 1984 (UK); Rules 36(2) and 43 provided:- "36(2) Neither the coroner nor the jury shall express any opinion on any other matters (than those set out in the equivalent to s.37 of the Act). 43. A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly." 15. Thurston, writing in 1980, in "Coronership" at pp.109-110 expressed his views on riders as follows:- "Riders seldom serve a useful purpose. A jury may

wish to suggest improvements to road conditions or recommend some change in a method of working. Advice to a jury in the inquest following the Princess Alice disaster in 1878 puts the position clearly: 'You should complain that the thing is

altogether unsafe and dangerous to life and that unless some alteration is made other lives will be endangered, but do not, as a jury, suggest any remedy because if you do the result might be that parties implicated might claim to be relieved of responsibility owing to the advice that a jury had said ... that a scaffold ought to be built that way or a ship required to sail this side or that side ... make any suggestions that something wants attention the same as if you were in your own home, you would say "This must be looked into, but inasmuch as I am not an architect or a surveyor I shall not suggest that it is to be done in a particular way, but do it, make some alteration to make things safe."' A coroner sitting without a jury seldom records a rider but he may draw to the attention of an authority or the management of a business that a state of affairs is dangerous and should be remedied. This may be stated in court or be the subject of a letter." Section 40 provides: "Where - (a) an inquest - - has been held; and (b) the Supreme Court, on an application made by or under the authority of the Minister, is satisfied that, by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, discovery of new facts or evidence or otherwise it is in the interests of justice that the inquest - - be quashed and that another inquest - - be held, the Supreme Court may order that the inquest - - be quashed and may order a Coroner to arrange for the holding of another inquest - - and that Coroner shall thereupon hold or arrange for another Coroner to hold such an inquest - - accordingly." (emphasis mine) (b) The history of the institution of Coroner 16. The Act must also be read and understood generally against the background of the long history of the office of Coroner. It has served a function in the law for some 800 years, formerly in a more vital way than at present. See generally Thurston, op cit., Chapter I; and J. McKeough "Origins of the Coronial Jurisdiction" (1983) 6 NSWLJ 191. The King's Court always had a power of oversight and review of Coroners Courts; it was itself "supream (sic) coroner throughout England" - see Stanlack's case [1726] EngR 760; 1 Vent 181; 86 ER 123. (c) Conclusions 17. The general jurisdiction vested in this Court under s.14(1)(b) of the Supreme Court Act includes the common law power of superior courts of record to review the decisions of Coroners Courts. That such a power exists at common law is clear; see Mirror Newspapers Ltd v Waller (1985) 1 NSWLR 1; Bilbao v Farquhar (1978) 1 NSWLR 528 at p 532, per Moffitt P; and In re Rapier (dec'd) (1988) QB 26 at p 28 per Woolf L.J., and at p 37 per Simon Brown J. Mr Riley submits, however, that the common law power must be read subject to statute, and the Coroners Act constitutes a code. Hence, he submits, the effect of s.40 of the Act (see above) is that the Attorney-General is now the statutory "filter" for any application to quash. I note that in some other jurisdictions legislation corresponding to the Coroners Act contains provisions which either expressly preserve the common law jurisdiction or expressly enable other persons, as well as the Attorney-General, to make an application for review. See, for example, as to the former, s.37 of the Coroners Act 1887 (UK); and as to the latter, s.47(2) of the Coroner's Act (NSW) (the provision corresponding to s.40 of the Territory Act) which provides that the application may be made "by, or under the authority of, the Minister or by any other person." (emphasis mine) 18. Mr Hiley submits that on its proper construction s.40 of the Coroners Act provides rights which are additional to those provided by the common law; it provides a means, via the fiat of the Attorney-General, whereby a person may invoke the supervisory jurisdiction of the Supreme Court when at common law he had no standing to do so. 19. I consider that the better view is that in the Northern Territory any person with locus standi at common law may apply to this Court for judicial review of a coronial inquiry without relying on obtaining the Attorney-General's fiat under s.40. Further, any person who is dissatisfied with the findings of a Coroners Court may approach the Attorney-General for his fiat under s.40 to apply to have the inquest quashed and a second inquest held. Through the statutory provision the Attorney-General acts as a filter to exclude frivolous or vexatious applications. In New South Wales, I note, this "filtering" function has been removed. 20. An applicant for certiorari who does not seek the Attorney-General's fiat must have sufficient interest in the Coroner's decision to entitle him to seek judicial review. That is a requirement of the common law. The modern test of locus standi was propounded by Lord Denning M.R. in R v Liverpool Corporation; ex parte Liverpool Taxi Fleet Operators' Association (1972) 2 QB 299 at pp 308-9:- "The writs of prohibition and certiorari lie on behalf of any person who is a "person aggrieved", and that includes any person whose interests may beprejudicially affected by what is taking place. It does not include a mere busybody who is interfering in things which do not concern him; but it includes any person who has a genuine grievance becausesomething has been done or may be done which affects him - - -." (emphasis mine) 21. To be a "person aggrieved" by a decision the applicant need not be a party to that decision. In Maksimovich v Walsh(1983) 2 NSWLR 656 a person who had been permitted to be represented at a Coroner's inquiry and who might suffer adverse publicity and damage if named by the Coroner, was held to have sufficient standing to apply for orders securing the fulfilment by the Coroner of his duty under the Act (not to suggest in open Court that an offence had been committed by any named person). 22. Mr Hiley submits that here the Director was affected by the likelihood of adverse publicity, stemming from the Coroner's findings. In that connection, Mr Riley has conceded that if this Court has the power to entertain the Director's application for certiorari - as I have held it has - the Director was a person with sufficient interest to bring such an application. The concession was rightly made. (His Honour referred to the Director's position, and continued:) it is clear that the Director had sufficient interest to be represented thereat. It follows that he has sufficient standing to make this application. 23. I turn now to the first of the three grounds on which the Director bases his claim for relief. Denial of natural justice 24. The Director complains that he was not afforded natural justice by the Coroner. Specifically, Mr Hiley submits that where a Coroner is likely to make a finding which is adverse to a person, natural justice requires that:- 1. the person concerned be made aware of that possibility; and 2. he be given the opportunity to place before the Coroner such information, evidence or submissions as might persuade the Coroner not to make such a finding. 25. Mr Hiley's argument proceeded as follows. In R v Deputy Industrial Injuries Commissioner; ex parte Moore (1965) 1 QB 456 at p 488 are set out two rules of natural justice which Mr Hiley submitted were applicable here:- "First, he (the Commissioner) must base his decision on evidence, whether a hearing is requested or not. Secondly, if a hearing is requested, he must fairly listen to the contentions of all persons who are entitled to be heard at the hearing." 26. Moore's case (supra) involved a claim for an industrial injury benefit; the breach of natural justice complained of was that the Commissioner had treated as evidence before him certain medical opinions expressed in previous cases. The Court of Appeal held that both parties and their witnesses had had full opportunity of commenting on those opinions, and so no breach of the rules of natural justice was involved. At p 476 Willmer L.J. identified two rules of natural justice which applied:- "Where so much is left to the discretion of the commissioner, the only real limitation, as I see it, is that the procedure must be in accordance with natural justice. This involves that any information on which the commissioner acts, whatever its source, must be at least of some probative value. It also

involves that the commissioner must be prepared to hear both sides, assuming that he has been requested to grant a hearing, and that on such hearing he must allow both sides to comment on or contradict any information that he has obtained. This would doubtless apply equally where a hearing had been requested but refused, for in such a case it would not be in accordance with natural justice to act on information obtained behind the backs of the parties without affording them an opportunity of commenting on it." 27. The general applicability of the first rule is obvious. As to the second, it may be noted that a Coroner's inquest is an investigation by inquisition, in which no one has a right to be heard. There are no "sides", in the sense of adversary litigation. 28. In Attorney-General v Maksimovich (1985) 4 NSWLR 300, the question was whether the Coroner, when terminating his inquiry as required under s.19(1) of the Coroners Act (NSW) because he was of opinion that the evidence established a prima facie case against a known person for an indictable offence, could state in public his reasons for doing so, naming the persons he suspected. The person complaining had been a witness in the coronial enquiry who had been summonsed to attend it. He was an interested party. Kirby P said at pp 311-2:- "- - - a principle of natural justice must be kept in mind. If a person is to be named in a statement, signed by the coroner and sent to the Attorney-General under s.19(2), fairness would appear to require that he should know of this fact and that any others who are not to be so named should likewise be informed. Otherwise, it is said, a person affected may have significant decisions made concerning him without the opportunity to place before the Attorney-General such information, evidence and submissions as might affect the Attorney's decision. In Mahon v Air New Zealand Ltd [1983] UKPC 29; (1984) AC 808 a case of judicial review of the conduct of a Royal Commissioner, the Privy Council made it plain that in that context persons who might be adversely affected by the decision should be given the opportunity to place relevant matters before the decision-maker (at 820-821): "The rules of natural justice that are germane to this appeal can, in their Lordships' view be reduced to those two that were referred to by the Court of Appeal of England in Reg v Deputy Industrial Injuries Commissioner: Ex parte Moore (1965) 1 QB 456, 488, 490, which was dealing with the exercise of an investigative jurisdiction, though one of a different kind from that which was being undertaken by the judge inquiring into the Mt Erebus disaster. The first rule is that the person making a finding in the exercise of such a jurisdiction must base his decision upon evidence that has some probative value in the sense described below. The second rule is that he must listen fairly to any relevant evidence conflicting with the finding and any rational argument against the finding that a person represented at the inquiry, whose interests (including in that term career or reputation) may be adversely affected by it, may wish to place before him or would have so wished if he had been aware of the risk of the finding being made ... The second rule requires that any person represented at the inquiry who will be adversely affected by the decision to make the finding should not be left in the dark as to the risk of the finding being made and thus deprived of any opportunity to adduce additional material of probative value which, had it been placed before the decision-maker, might have deterred him from making the finding even though it cannot be predicted that it would inevitably have had that result."

(emphasis mine) 29. Accordingly, it is said, it would be wrong to leave the public "in the dark" concerning the reasons for the determination of the inquiry. But it would be even more wrong to leave in the dark a person who might be affected by the statement to be sent to the Attorney-General. Such a person should be given the opportunity to influence the vital decision that might otherwise be made to initiate criminal proceedings against him "in the dark", (and not) denied through ignorance the opportunity to place material and submissions before the Attorney-General which might influence his decision. 30. It can be seen that the question with which Kirby P was dealing differed to that raised in the present case; it was concerned with the application of natural justice to a person before the Coroner. 31. A coronial inquiry is not a judicial proceeding. In R v West London Coroner; ex parte Gray (1988) QB p 467 at p 473 Watkins L.J. described its nature in the striking words used by Lord Lane C.J. in R v South London Coroner; ex parte Thompson, The Times, 9 July 1982:- "Once again it should not be forgotten that an inquest is a fact finding exercise and not a method of apportioning guilt. The procedure and rules of evidence which are suitable for one are unsuitable for the other. In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts. It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends, the judge holding the balance or the ring, whichever metaphor one chooses to use." (emphasis mine) 32. It is clear that the rules of natural justice apply to a coronial inquiry; see Maksimovich v Walsh (1985) 4 NSWLR 318 at pp 327 and 337. But the requirements of those rules vary according to the circumstances of the case. In a different factual situation, in Maksimovich v Walsh (supra) at p 341 Samuels J.A. said:- "I emphasise that the point taken is that the Coroner

should not have commenced the inquiry at all without advising the appellant (who had been summonsed as a witness) to get legal representation, "having regard to the serious matters alleged against him". There can be no general principle of natural justice which would entail the provision of that advice. The question is whether, in the specific circumstances of this case, rules of fairness required the Coroner to offer it. - - - I am doubtful whether this material can be said to constitute an "allegation" of serious matters against the appellant. At all events the appellant must have been perfectly well aware that the police had suspicion about the possibility of his involvement. - - - The transcript indicates that he understood, from the beginning, that he had a right to legal representation, but evidently decided not to exercise it. - - - This Court must, of course, scrutinise matters of this kind from the standpoint of general principle, and we must therefore be careful not to attach undue weight to the particular capacity of a protagonist. But we are also enjoined to keep in mind that the

content of the rules we are to apply does depend upon the circumstances of the case. The passage from (Russell v Duke of Norfolk (1949) ALL ER 109 at 118) quoted above has been frequently approved and the protean nature of the requirements emphasised: - - - In my opinion there was no rule of fairness which, in the circumstances of this case, required the Coroner to give the advice suggested." (emphasis mine) 33. I respectfully agree with the observations to the same effect of Kirby P. in Maksimovich v Walsh (supra) at p 327:- "As it seems to me, the debate is not whether a coroner must accord natural justice to witnesses appearing before him. Rather, given the special history of his office, the functions of his inquiries, the term of the legislation governing him and the controls upon the outcome and record, it is what content those rules of natural justice should have". (emphasis mine) 34. See also Bond v Australian Broadcasting Tribunal (No.2) (1988) 84 ALR 646 at pp 658-9, per Wilcox J, on the general context of the common law duty to give natural justice to a person potentially affected by the outcome of an inquisitorial proceeding. Again, this was in the context of an inquiry into activities of the applicant. 35. Mr Hiley submits that in the circumstances of this case natural justice required that the Coroner give the Director notice of the views he had formed on the evidence, and afford the Director an opportunity to be heard, before he made his findings public. For this proposition he relied on National Companies and Securities Commission v The News Corporation Ltd [1984] HCA 29; (1984) 156 CLR 296. In that case the Commission was inquiring into the affairs of the defendant which was represented at the hearing. The Commission indicated that it proposed to meet in private. At p 306 Gibbs C.J. framed the question for resolution as follows:- "The question in the present case is whether, when the Commission suspects that a person has committed a contravention of the Companies Act, and holds a hearing to investigate whether such a contravention has occurred, and to decide whether, if a contravention has occurred, an application should be made to the Supreme Court, the rules of naturaljustice, or the very fact that what is held is a "hearing", oblige the Commission to permit the person suspected of having committed the contravention and his legal representatives to be present throughout the whole of the hearing and to cross-examine witnesses, give evidence in reply, and make submissions to the Commission before it makes any findings." (emphasis mine) 36. It can be seen that this poses for consideration a different requirement of natural justice to that suggested by Mr Hiley in this case. The circumstances were different; the cases are not analogous. 37. At p 309 his Honour noted the Commission had no issue to decide, its hearing being for the purpose of discovering facts and not to make a finding of fact, its procedure being inquisitorial. 38. At p 312 his Honour said: "The authorities show that natural justice does not require the inflexible application of a fixed body of rules; it requires fairness in all the circumstances, which include the nature of the jurisdiction or power exercised and the statutory provisions governing its exercise. Moreover, as Stephen J said in Salemi v MacKellar (No.2) ((1977) [1977] HCA 26; 137 CLR 396, at p 444) the rules of natural justice "may also vary from case to case although each be conducted before one and the same tribunal or person." It is important to consider exactly what the Commission is empowered to do in a case such as the present. Counsel for the respondents relied on the fact that the Commission intends to publish its decision, with detailed reasons, and possibly with an account of some of the evidence which was given in private; - - ". (emphasis mine) 39. At pp 315-6 his Honour said that assuming the two rules of natural justice referred to in Moore's case (supra) applied, they would be met:- "- - by the procedure which the Commission has suggested, namely, that if at the conclusion of the hearing, the Commission proposes to publish any matter adverse to or critical of any person, it will afford him or it an opportunity to be heard and call evidence on such matter before proceeding further - - -." 40. Mr Hiley submits that the same approach was required here by the rules of natural justice and should apply where the complainant was not represented before the tribunal. It may be noted that the Commission was inquiring into the affairs of the defendant; that is not the purpose of a coronial inquiry. 41. Attorney-General v Maksimovich (supra) is authority for the proposition that if a person is to be named in a statement signed by the Coroner and forwarded to the Attorney-General, fairness requires that he be informed and given an opportunity to place before the Attorney-General such information evidence and submissions as might affect the Attorney-General's decision to prosecute. The Director in the present case does not face criminal proceedings as a result of the Coroner's findings, but Mr Hiley submits that he may face civil proceedings as a result; accordingly, he submits, the principle in Attorney-General v Maksimovich (supra) applies. I do not consider that the analogy with criminal proceedings holds. I note that there is no finding of civil liability by the Coroner and evidence before the Coroner cannot be used in subsequent civil proceedings. 42. Maksimovich v Walsh (supra) is cited as authority for the proposition that the Coroner had a duty to require the NPWS to be represented, before he made his findings. The plaintiff in that case was given the opportunity to have legal representation at the coronial inquiry and chose not to take advantage of that opportunity. The Court held that in those circumstances he could not be heard to complain. At p 329 Kirby P. said:- "The appellant was a businessman with interests in a number of business enterprises. It would be naive to suggest that he was unaware of police suspicion, which in any case present themselves by reason of the coincidental happening of four fires in premises, the only link between which appears to have been the interest of the appellant. In any case, in the manner in which the proceedings were conducted, before legal representatives were secured, I can see no relevant unfairness or prejudice to the appellant which requires the intervention of this Court. I would reserve to another case, and different circumstances, the extent to which the law imposes a duty upon a coroner or other judicial officer to offer a warning of the desirability of securing legal representation. I would not wish anything I have said to discourage such warnings being given, particularly where a person is brought before a judicial officer, is under suspicion of criminality, appears to be unrepresented and has difficulties with the English language." (emphasis mine) 43. See also the earlier citation from the opinion of Samuels J.A. at p 341. In that case the plaintiff had appeared before the inquiry, whereas here the Director had not; the circumstances were entirely different. 44. The Director says that he was not notified of the inquest and was not represented at the hearing. Mr Chuk, a senior officer of the NPWS, testified before the Coroner on 20 July 1988. Mr Hiley contends that Mr Chuk appeared on that occasion only to give evidence of his involvement in the search for Graebner, and was not to be taken as representing the NPWS. I note that at the time he gave evidence Mr Chuk was the Acting Park Superintendent; he was the District Supervisor of the NPWS at the time of the search for Graebner. 45. Mr Riley concedes that the rules of natural justice apply to coronial inquiries. However, he submits that in circumstances such as obtained here, where the Director "must have been perfectly aware" of his likely involvement, the application based on a non-compliance with requirements of the rules of natural justice of the type contended for, should be rejected. He submits that the failure by the Director to appear and present evidence before the Coroner flowed from his own failure to seek representation at the inquest; it would have been expected of him (as clearly the Coroner expected of him) that he would seek to be represented, in the circumstances. These circumstances included:- 1. the fact that the Director was the controlling authority of the Park in which Graebner died; 2. the death of Graebner was the second death in similar circumstances in the same locality, within approximately 12 months; and 3. the incident was considered sufficiently serious for NPWS to close the route to walkers. 46. As to the Director's assertion that he was not notified of the hearing, Mr Riley points out that the relevant senior officers of the NPWS on the spot were certainly made aware that the inquest would commence at Yulara on 21 July 1988. He also points to parts of the transcript where Mr Chuk appeared to speak with some authority, for the NPWS. His Honour referred to the matters dealt with by Mr Chuk and continued. 47. Mr Riley submitted that it was not for the Coroner to chase every potential person who might wish to express a view at the inquest, or every interested person in terms of s.32(b) of the Act. Where a person had adequate notice of the date of the inquest and chose not to attend, or to seek to be legally represented, or failed to give notice that he was unable to attend or to seek to be represented, the Coroner was quite entitled to continue with his deliberations in the absence of that person. I agree entirely with this proposition. It is important that the concept of natural justice not be discredited by imposing unreasonable requirements and undue burdens on those who are under a duty to act fairly. Ostreicher v Secretary of State for the Environment (1978) 1 WLR 810 involved a party who did not attend an inquiry directed to the amount of compensation arising from a compulsory purchase order, after notice had been given; I consider the approach adopted there is equally applicable to this inquiry. 48. Mr Riley submitted that in the circumstances of the case the Coroner was entitled to proceed as he did, on the basis of his own investigations and the materials placed before him by counsel assisting him. I consider it is important in this regard to bear in mind that a Coroner's inquiry does not involve the presence of parties, as such; no person and no lawyer, as such, has locus standi. Anyone at all is at liberty to seek to place evidence before the Coroner's inquest, and to seek to be legally represented. 49. In all the cases on which Mr Hiley relied in support of the proposition that the Coroner had an obligation to inform the Director of the likelihood of findings adverse to him before proceeding to his findings under s.37 of the Act, the person concerned was before the tribunal in one way or other. In general, I consider that it is preferable to deal with the question of what the requirements of natural justice are, by reference to the actual facts of the particular case. No authority, however, was cited for the proposition that the Coroner must seek out persons who had been made aware of the inquest and had not sought leave to appear before him, and warn them that what he proposed to say might be adverse to their interests. I consider that a person who has been notified of the date of the inquest by the Coroner, has sufficient interest to seek leave to appear at that hearing, and does not choose to do so, cannot be heard to complain of a denial of natural justice and lack of fairness of the type on which Mr Hiley here relied; see generally Maksimovich v Walsh (supra). 50. The question then is: was sufficient notice of the inquest given to the Director? The Coroners Act is silent as to any requirement that the Coroner give notice of an inquest. Jervis on Coroners (10th Ed) at pp 138-139 states:- "It is desirable, but not a legal necessity, that due public notice of the holding of an inquest should be given, as it may be by exhibiting beforehand a notice of the place of inquest, or by answering enquiries from the Press. Notice (under Rule 19 the Coroners Rules 1984 (UK))

of the time and place of the inquest must be given to any spouse, near relative or personal representative of the deceased whose name and address are known to the Coroner, and to any other person whom the Coroner considers to be entitled to examine the witnesses at the inquest, and who, having asked the Coroner to notify him of the time and place of the inquest, has

supplied the Coroner with a telephone number or address for the purpose of being so notified. The Coroner must also give (reasonable) notice of the time and place of the inquest to any other person whose conduct is likely in the Coroner's opinion to be called in question at the inquest." (Coroners Rules 1984 (UK), R.24) (emphasis mine) 51. I note that there is no equivalent in the Territory of the Coroners Rules 1984 (UK), or the previous Rules of 1953. It appears to be desirable that appropriate Rules or Regulations be formulated, pursuant to s.53 of the Coroners Act, to regulate the practice and procedure at and in connection with inquests more closely than hitherto. 52. Very properly, Mr Hiley conceded that the NPWS was aware of the inquest; see p 31 of the transcript. As noted earlier, there can be no doubt that the two senior officers of NPWS at Uluru National Park were aware of the hearing. Mr Chuk was requested to attend the inquest to give, as he described it, "evidence as to my involvement in the search." He also informed the Parks Superintendent, Mr Morgan, that he would be attending the inquest to give evidence. In view of the fact that the senior officer of the NPWS at Uluru had ample notice of the time and date of the inquest, I consider that in the circumstances the Coroner clearly discharged the common law duty, if any, which he had to notify the Director of the hearing. 53. That is to say, the Director, through his senior officers on the spot, had sufficient notice of the inquest. It was then for the Director to seek leave to be legally represented at the inquest, if he wished to do so to protect his position. This is common practice by public authorities. The Director has access to the legal resources of the Australian Government Solicitor. At the adjournment of the first hearing in July 1988, following the evidence of Mr Chuk who had spoken with some authority on matters relating to the Park, the Director must be taken to have been aware through his senior officer at Uluru of the issues of obvious concern to the Coroner. The Director did not seek representation at the resumed hearing 3 weeks later. 54. Mr Hiley submits that simply because a person is not present at an inquest the Coroner is not excused from his duty to accord that person natural justice. That appears to be correct. The question, though, is rather what the requirements of that duty entail, in that situation. I consider that where a person may seek to be represented at an inquest under s.32(b) of the Act, is aware that he may do so and aware of the date of the inquest, yet does not attend or seek to be represented thereat, the requirements of natural justice to be accorded to him do not extend to imposing a duty on the Coroner to seek him out and inform him of his concerns. That would impose an intolerable burden on Coroners and unnecessarily delay their work. In the circumstances of this case, I consider that the Director was not denied natural justice by the Coroner. 55. I turn to the second of the three grounds on which the Director relies. Error of law 56. Mr Hiley submits that the Coroner erred in law in that he made findings which were unsupported by the evidence before him. 57. A finding of primary fact involves an error of law if there was no evidence to support that finding, or if the finding could not be reasonably supported on the evidence. However, as Brennan J made clear in Waterford v The Commonwealth [1987] HCA 25; (1987) 163 CLR 54 at p 77: "There is no error of law simply in making a wrong finding of fact." See also the discussion in Australian Broadcasting Tribunal v Bond ((1990) [1990] HCA 33; 64 ALJR 462) per Mason C.J. at p 477. His Honour there said:- "Thus, at common law, according to the Australian authorities, want of logic is not synonymous with error of law. So long as there is some basis for an inference - in other words, the particular inference is reasonably open - even if that inference appears to have been drawn as a result of illogical reasoning, there is no place for judicial review because no error of law has taken place." 58. Mr Hiley handed up a document entitled "Relevant Findings and Comments" detailing some 37 items. They are noted in the margin to Annexure "A" as items A - AK. This document makes a brief observation about many of these items, which Mr Hiley elaborated on in his address. After making submissions about these matters, Mr Hiley sought the quashing of several of the "findings". Mr Riley contended that not all of the items complained of were "findings"; some were recommendations and comment and thus, he submitted, not capable of being quashed. He submitted that the findings complained of were findings open to the Coroner. I turn to the submissions made by both counsel relating to these matters. (His Honour then set out the submissions and continued:) 59. A question arises as to whether the findings of fact, comments or recommendations are, by themselves, subject to being quashed by certiorari proceedings. It is clear that if an ultimate decision is based on findings of fact which are not supported by the evidence, then that decision may be quashed. Here, however, the Court is asked to quash certain preliminary or collateral findings of the Coroner but not his final finding of accidental death. In Australian Broadcasting Tribunal v Bond (supra) at p 470 Mason C.J. said:- "However, in ordinary circumstances, a finding of fact, including an inference drawn from primary facts, will not constitute a reviewable decision because it will be no more than a step along the way to an ultimate determination. Of course an ultimate determination which depends upon a finding of fact vitiated by error of law or made without evidence is reviewable - - . In such a case the finding of fact may be challenged as an element in the review of the ultimate determination. But the point remains that ordinarily a finding of fact will not be susceptible to review independently of the ultimate decision." 60. It follows that findings of fact upon which a decision are based are not judicially reviewable in isolation from the decision itself. In principle, I do not consider that there is power to quash findings of fact by the Coroner which led to his ultimate finding of death by misadventure unless that finding itself is quashed; that is, unless it can be shown that the ultimate finding was severable from the findings complained of. (His Honour then distinguished Re Neuendorf (dec'd)(unreported, Rice J, 21 July 1989) on the facts, and continued:) 61. A further question for consideration is whether the Court has power to quash comments and recommendations made by the Coroner. Comments and recommendations are not binding on any person, can have no legal consequences and may be accepted or rejected at will by the person asked to consider them. The Coroner must base his comments and recommendations on evidence he has obtained by any means open to him. If the Coroner's opinions are reasonably held on the evidence before him, I do not consider that there is power to quash the comments and recommendations which reasonably flow from those views, on the ground that they involve an error in law. They may of course be subjected to criticism, as being in fact erroneously based; it was probably the fact that coroners or their juries added riders to their verdicts which were without foundation, which led to the legislative erosion of the power to add riders, in England. 62. In the light of the foregoing I decline to quash the matters complained of on the basis that they were rooted in errors of law. 63. I turn to the third of the 3 grounds on which the Director relies. Excess of jurisdiction 64. Mr Hiley submits that where comments and recommendations cannot be quashed on the grounds already dealt with, they should be quashed on the ground that in making them the Coroner exceeded the jurisdiction conferred on him by the Coroners Act. He submits that the only power the Coroner has to make recommendations is the statutory power conferred by s.9A(2) of the Coroners Act, set out earlier. 65. There is no other provision in the Coroners Act which refers to the making of recommendations or empowers the Coroner to make recommendations. The relevant powers and duties of the Coroner in relation to a person who dies in the circumstances described in s.10(1) of the Act are to:- (1) hold an inquest into the manner and cause of death - s.10(1); (2) ascertain certain particulars - s.10(4); (3) adjourn the inquest - s.26(2); (4) make full enquiry into the manner and cause of death - s.29(1); and (5) record his findings as to identity, time and place of death, manner and cause of death, 66. The record of the Coroner's findings are embodied in the "Inquisition"; form 16 in the Schedule to the Act is a "Form of Inquisition", though it appears to have no statutory basis. 67. Apart from the powers conferred by s.9A(2) of the Act, the only power which a Coroner could have to make recommendations is a power at common law, preserved in s.9A(1), set out earlier. 68. Mr Hiley submits that there is no common law power in a Coroner to make recommendations. He points to Rules 32, 34 and 27 of the Coroners Rules (UK) (1953) as conferring power on a Coroner in England (and his jury) to make recommendations confined to the prevention of the recurrence of similar fatalities. Recommendations so made are not part of the Coroner's findings; see R v Harding (1908) 1 Cr. App R 219. In the absence of empowering Rules such as the Coroners Rules in England, Mr Hiley submits that a Coroner in the Northern Territory has no power to include in his findings, comments on matters not required by s.37 of the Act. He submits that the Coroner's power to make recommendations is limited to that conferred by s.9A(2) of the Act; and in this case, obviously, the Coroner did not utilise that statutory power. 69. Mr Riley submits that the "recommendations" complained of were recommendations made by the Coroner with a view to similar tragedies being avoided in the future. Coroners have for many years made recommendations of this nature; they have no force in law, and no penalty or sanction attaches to a failure on the part of any person to act in accordance with them. Mr Riley submits that there is no prohibition or restriction on a Coroner making recommendations and there is no need that he should be specially empowered to do so. 70. In K.M. Waller's book "Coronial Law and Practice in New South Wales" (2nd ed., 1982) the learned author comments on s.22 of the Coroners Act (NSW), which does not explicitly grant a power to make recommendations, and says at p 52:- "At the conclusion of the evidence and addresses the Coroner may wish to sum up the evidence, giving reasons for his finding. This is not a universal practice, but it seems reasonable that the relatives, witnesses and public, are entitled to know not only the verdict, but also what evidence was accepted and what weight was given to various factors upon which considerations the Coroner arrived at his conclusions. The summing up will give him the opportunity of making observations as to safety procedures, recommendations to public bodies, commendations for bravery and for giving such warnings to the public as appear apt." 71. Mr Riley informed me that he had found no reported instance of a Coroner's recommendation being held to be ultra vires. 72. It will be recalled that s.9A(1) of the Coroners Act preserves all the "powers authority and jurisdiction" of a Coroner at common law. Mr Riley submits that the proviso to Rule 27 of the Coroners Rules (UK) (1953) (set out on p 13) acknowledged the common law power to make recommendations and was also intended to preserve that power. 73. Accordingly, Mr Riley submits that the power of the Coroner in the Northern Territory to make recommendations with a view to preventing similar fatalities is well founded in s.9A(1) of the Coroners Act. He submits that the statutory power to make recommendations by s.9A(2) of the Act is wide in scope, and includes such recommendations as the Coroner "thinks fit"; the power is not restrictive of the common law power to make recommendations but is an additional power permitting the Coroner to write direct to identified persons. 74. I accept Mr Riley's submissions that the Coroner in the Northern Territory has a common law power to make recommendations aimed at preventing similar fatalities. In the result recommendations made by the Coroner to that end cannot be quashed as being in excess of his jurisdiction. 75. In all the circumstances of this case I consider that it is not open to me to quash the findings, comments and recommendations complained of, for the reasons stated. Accordingly, I dismiss the Director's application, with costs. Observations 76. I noted earlier that it appeared desirable that Coroners Rules be made, to regulate properly the procedure of an inquest or inquiry. In England new Coroners Rules were made in 1984 which made quite comprehensive provision; see Rule 36(2), for example, abrogating as a matter of policy the former power to make public riders. Waller takes a different view in pp 6-8 of his book, on the utility of riders by Coroners. The position in Canada appears to be that the importance of riders is recognised. If riders are thought to be of value in the Territory, this adds to the desirability of the making of Coroners Rules.