Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
Coronial Inquest Recommendations
The Coroner’s Court of Victoria (CCoV) is responsible for investigating all reportable deaths, including deaths in custody. Following an investigation, the coroner makes findings as to the cause and circumstances of the death, and sometimes also recommendations that may help prevent similar tragedies.
Coronial investigations of deaths in custody may also consider internal departmental reports, namely those prepared by Justice Health which examine provision of healthcare, and the Justice Assurance and Review Office which examine custodial management and incident response. These reports are not publicly available.
The findings, recommendations, and subsequent responses of coronial investigations are then published online where an inquest was held, recommendations have been made, or a coroner otherwise orders they be published. However, this means that not all investigations into deaths in custody are published, as only a small proportion (less than five %) of investigations are held as public inquests and not all findings are accompanied by recommendations.
Concerns over lack of monitoring processes
Where a public statutory authority or entity has committed to action in response to coronial recommendations, there is limited ongoing monitoring of whether these actions have been carried out or if these actions have created change or prevented further deaths in custody.
The AJC has raised concerns over the lack of a consistent and transparent process that monitors progress of coronial recommendations in Victoria. There is a need to ensure recommendations made by the CCoV regarding Aboriginal deaths in custody are being addressed in full, to prevent future deaths in custody. Accordingly, this project will examine implementation progress of coronial recommendations arising from Aboriginal deaths in custody in Victoria since 1991. This will also allow systemic issues and responses to be identified.
