28Findings, &c., of coroner investigating a death

28 Findings, &c., of coroner investigating a death

(1)  A coroner investigating a death must find, if possible –

(a) the identity of the deceased; and

(b) how death occurred; and

(c) the cause of death; and

(d) when and where death occurred; and

(e) [Section 28 Subsection (1) amended by No. 58 of 1999, Sched. 1, Applied:01 Nov 2000] [Section 28 Subsection (1) amended by No. 1 of 2015, s. 9, Applied:21 Apr 2015] the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999 .

(f) [Section 28 Subsection (1) amended by No. 1 of 2015, s. 9, Applied:21 Apr 2015] .  .  .  .  .  .  .  .  

(2)  A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate.

(3)  A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.

(4)  A coroner must not include in a finding or comment any statement that a person is or may be guilty of an offence.

(5)  [Section 28 Subsection (5) amended by No. 72 of 2005, s. 78, Applied:20 Feb 2006] [Section 28 Subsection (5) amended by No. 2 of 1998, Sched. 2, Applied:01 Jul 2000] [Section 28 Subsection (5) amended by No. 49 of 1999, Sched. 1, Applied:01 Feb 2000] If a coroner holds an inquest into the death of a person who died whilst that person was a person held in custody or a person held in care or whilst that person was escaping or attempting to escape from prison, a secure mental health unit, a detention centre or police custody, the coroner must report on the care, supervision or treatment of that person while that person was a person held in custody or a person held in care.