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He Handles Death Daily, but Singapore’s Top Coroner Takes Pride in Giving Loved Ones Closure

More than twenty years since Mr Adam Nakhoda first became a coroner, one particular case remains foremost in his mind.

A woman was crossing a road with her five-year-old son, while pushing her two-year-old daughter in a baby stroller, when a car struck them. All three succumbed to their injuries that night in 2000.

As a field coroner at the time, Mr Nakhoda was in the mortuary when the woman’s husband was brought in to identify the bodies.

The scene has stuck with Mr Nakhoda.

“The father was absolutely devastated, and his emotional state got more fraught as each of his loved ones were brought in (on hospital gurneys),” he recounted sombrely.

“That’s something that remains with me to this day … and that would be an example of where this job can be quite emotionally difficult.”

With the advent of video technology, coroners generally no longer have to go to the mortuary to view a body. But the job remains hard to deal with in other ways, especially when children or young people lose their lives, said Mr Nakhoda, who is now Singapore’s top coroner.

In a rare interview, Mr Nakhoda spoke to CNA about his work determining the causes and circumstances of sudden or unnatural deaths in Singapore.

To those in legal circles, the 52-year-old has been a familiar face for years. He first joined the Subordinate Courts – now known as the State Courts – in 1999, before becoming a prosecutor in 2004.

He then went over to the Competition Commission of Singapore, rising to deputy director of its legal and enforcement department.

In 2014, he made his return to the State Courts, cutting a stern figure as a sentencing judge in criminal courtrooms before being appointed State Coroner in June 2021.

Since then, while working closely with forensic pathologists and investigation officers to piece together what could have led to someone’s untimely demise, Mr Nakhoda has helmed several high-profile coroner’s inquiries.

These include the Tanjong Pagar car crash that killed five men; the death of a jogger struck by a termite-infested tree; Singapore’s first death linked to a COVID-19 vaccine; and the electrocution deaths of three family members due to a faulty water heater.

This is no small task. About 5,000 unnatural deaths on average are reported in Singapore every year. While a majority of these cases are closed on the first day, 20 to 25 per cent eventually warrant a full investigation by the State Coroner.

A few other district judges also serve as coroners.

The cases they handle can be extremely technical, and come with their own set of challenges.


Misconceptions among the public and managing the expectations of the bereaved are also issues that coroners have to grapple with, with emotions running high after a sudden death.

One common misunderstanding, Mr Nakhoda pointed out, is that a coroner determines if someone was responsible for a death. For example, when a pedestrian dies in a road accident, loved ones sometimes expect the coroner to make a finding that the driver was to blame.

The Coroners Act – a set of laws that governs coronial proceedings in Singapore – states that a coroner is not supposed to ascribe liability, whether it be criminal, civil or disciplinary.

After an inquiry, prosecutors may proceed to charge individuals in court based on the coroner’s findings.

Mr Nakhoda said: “Often, I need to explain to next-of-kin during the coroner’s inquiry that I will not be finding anyone at fault; the process is not fault-finding.

“If they feel that there is fault or someone is responsible for the deceased’s death, then they need to bring other actions in order to establish that.”

Mr Nakhoda reminds himself that next-of-kin are understandably upset about events.

“They might be very angry, so I have to remember – when I deal with them, deal with them with as much empathy as possible,” he said.

“I think that will be the greatest challenge: Trying to let the next-of-kin know the limitations that I have as a coroner.”

It is also a misconception that next-of-kin can object to an autopsy of their loved one.

The decision is actually a “fairly objective” one on his end, said Mr Nakhoda. An autopsy must be conducted if there is no known cause of death and a forensic pathologist cannot establish one from the deceased’s medical records or post-mortem computed tomography (CT) scans, or if someone dies under unnatural circumstances.

Another mistaken view that Mr Nakhoda sees among the public is that coroner’s inquiries can be held in private, without members of the public or media present.

This can only be done “in very limited circumstances” given that these inquiries, like almost all cases in Singapore’s judicial system, are held in open court, he said.

He was also of the opinion that journalists should be present to report on coroner’s inquiries, as it is “the primary way that we have to highlight the circumstances of certain deaths in order to prevent similar deaths from happening in the future”.

Nevertheless, he acknowledged that some next-of-kin are wary of their names being publicised in news reports.

For his part, he tries to give them some privacy by anonymising their names as much as he can in his coroner’s findings.


Mr Nakhoda’s typical day starts with going through reports on coroner’s cases, which can range from five to 25 a day. 

These in general involve an unknown cause of death, unknown identity of the deceased or the deceased being in police custody or destitute.

He then forms a preliminary view on whether an autopsy should be carried out, in consultation with forensic pathologists from the Health Sciences Authority.

These days, coroners rarely have to physically head down to the mortuary.

They only do so if someone dies in a homicide or if their identity is unknown; this allows them to immediately instruct investigation officers on how to confirm a deceased person’s identity, such as giving permission for DNA to be extracted.

When Mr Nakhoda is done with the reports, he hops on a video call with the pathologists to discuss whether an autopsy needs to be done. He can also view the body through video conferencing if necessary.

If the pathologist can identify a natural cause of death after examining a body and putting it through a CT scan, the process ends there. Mr Nakhoda signs a coroner’s certificate and allows the body to be released to family members.

If the pathologist recommends an autopsy, Mr Nakhoda will give permission for one to be carried out.

He then decides whether it is necessary to hold a coroner’s inquiry. This is mandatory in certain circumstances, including when someone dies in an industrial or road traffic accident.

Coroners are also tasked with giving consent if family members want to donate a deceased person’s organs for medical therapy, education or research purposes. This must not affect investigations into the cause of the death.

Mr Nakhoda next has to prepare for coroner’s inquiries – he typically holds one a day in the coroner’s courtroom at the State Courts.

While most inquiries take just a few hours, they can stretch on for longer or even over multiple days, depending on the complexity of the case.

When the working week is over, Mr Nakhoda occasionally heads to the mortuary on weekends to meet with the forensic pathologists.


Being so deeply involved in death on a daily basis would take a mental toll on anyone, but Mr Nakhoda admitted to growing used to it.

“The state of the deceased person doesn’t affect me as much as the circumstances or the reasons why they have passed away,” he said.

Technology may have helped coroners minimise certain emotionally draining aspects of the job – like viewing the bodies of those who died in traumatic circumstances – but it has also, in a way, added to it.

Mr Nakhoda pointed to the ubiquitous in-vehicle cameras – or dashcams – that record video footage of road accidents. While crucial for investigations, viewing the literal point of impact of an incident can be difficult.

“You see the suddenness of what has happened to these people, and I suppose you think about the next-of-kin not having had any time to say goodbye as they might have had in other cases,” he said.

Other types of cases that particularly affect Mr Nakhoda are suicides of young people as well as a more recent phenomenon: Personal mobility devices catching fire and leading to fatalities.

In one such incident in 2021, a 49-year-old woman lost her life when her son left lithium-ion cells in battery packs to charge on top of an illegally modified PMD he had bought on Carousell. This sparked a fire that consumed the cluttered contents of their flat.

The latest statistics from the Singapore Civil Defence Force also showed a rise in fires involving PMDs and power-assisted vehicles in the first half of this year, compared to the same period last year.

Through his coroner’s findings, Mr Nakhoda also hopes to stop the same tragic outcomes from happening again and again.

“I think highlighting these cases as well as the dangers of modified PMDs has a lot of utility,” Mr Nakhoda added.

“Hopefully, people who read the (news reports) on these cases will think again about purchasing modified PMDs or modifying their PMDs.”

The same goes for a recent case he presided over – a freak accident in 2021 involving a 48-year-old woman hiking in a forested area in Upper Bukit Timah. She died when a concrete slab at an abandoned village broke in half and crushed her

The episode will hopefully remind others to be more careful in such areas, and avoid getting into the same situation, said Mr Nakhoda.

When such cases make it to news articles, his three daughters aged eight to 12 also ask their father about what he does.

He described himself as “fairly candid” with them but also careful with details. Mr Nakhoda also makes sure the children are not around when he works at home and looks at graphic images, such as a body of a deceased person who fell from height.

“It’s important for (my kids) to know what I do, and again, I will explain to them that I’m trying to assist in investigating why someone has passed away, and maybe my work … might lead to similar deaths being prevented,” said Mr Nakhoda.

“I try to tell them, it’s not just gory pictures or death, but there is a positive aspect to what I do as well.”

He also finds satisfaction in being able to give bereaved individuals a sense of closure through his investigations and findings.

“They’re now able to move on and move past the concerns that they might have had,” Mr Nakhoda added.

“When I hear this, I think, yes, I have done the job that I’m supposed to be doing.”

Source : CNA