An Inquest is a formal court proceeding that allows for the public presentation of all evidence relating to circumstances surrounding to a death.

An Inquest may be held to inform the public of the circumstances of the death where it will serve some public purpose; to bring dangerous practices or conditions to the knowledge of the public and facilitate in formulating of recommendations to avoid preventable deaths.

An Inquest is mandatory when a person has died while detained or under custody.

A six-person jury is chosen from the jury roll and swear or affirm to "diligently inquire into the death and determine on the evidence presented at the Inquest his/her identity, how, when, where and by what means the deceased came to his or her death and without partiality or bias towards any person render a true verdict."

No one is on trial at an Inquest. The presiding Coroner and the Coroner's counsel assisting the presiding Coroner must protect the goals of the Inquest - to bring out the facts relating to the circumstances of the death in a fair and neutral approach and allow the jury to make useful and practical recommendations that may prevent similar deaths in future.

The strict rules of evidence do not apply at an Inquest but proper courtroom behaviour and protocol are required to protect the importance and integrity of the proceeding. Witnesses are summoned to testify about their knowledge of or involvement in the circumstance of death. With the assistance of the Coroner's Counsel and the presiding coroner, jurors may ask questions of witnesses. Physical evidence may be entered as exhibits. Following the presentation of the evidence, parties will be allowed to address the jury and make suggestions about their findings and possible recommendations. The Coroner's counsel will make submissions and then the presiding Coroner will charge the members of the jury, reminding them of their oath and advising them of the law as it applies to their verdict.

The jury’s findings and recommendations will be read out loud by the Inquest Coroner as part of the inquest proceedings. The Inquest Coroner will then conclude the inquest.

While the Coroner or jury may make a general recommendation designed to prevent similar deaths, they do not decide whose fault it was or whether there was a criminal offence.