Coroner, scope of inquest
Conway v Jerram, Magistrate and NSW State Coroner  NSWCA 319.
47. YOUNG JA : Yes, I agree. It is clear that a coroner has a wide, but not unlimited, mandate to hold or not hold an inquest concerning the death of a person. When an inquest is held, the scope depends on all the circumstances. The inquest may be held to determine who is the deceased, when and how he or she died and this is the primary purpose of the inquest.
As O'Keefe J said in X v Deputy State Coroner for NSW  NSWSC 46; 51 NSWLR 312 at 325 :
"The primary duty of the coroner conducting an inquest is to determine and record if a death has occurred and, if so, the identity of the deceased, the date and place of the death and the manner and cause of such death".
It is important that extraneous factors do not get in the way of that primary duty.
48 Just what is the scope of the inquest, is a matter for the coroner: a matter to be exercised using proper discretion and commonsense.
As the ACT Full Supreme Court said in Re Doogan; Ex parte Lucas-Smith  ACTSC 74; 193 FLR 239, 246 , in connection with the tragic Canberra bushfires, the coroner is not to conduct "a wide ranging inquiry akin to that of a Royal Commission, with a view to exploring any suggestion of a causal link, however tenuous, between some act, omission or circumstance and the cause", in that case, of a fire.
49 In the usual cases of death, a line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event.
50 As I say, it is a matter for the exercise of discretion and commonsense by the coroner. In this case, the evidence shows, the senior coroners who considered the matter, directed their minds to these matters and made their decision. Justice Barr also directed his mind, examined what the coroners did and came to a decision, a discretionary decision, well within his mandate.