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Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
This is a RCIADIC recommendation
10
Custodial authorities immediately notify Coroner of all deaths
That custodial authorities be required by law to immediately notify the Coroners Office of all deaths in custody, in addition to any other appropriate notification.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 10 was to legally require custodial authorities to immediately report deaths in custody to the coroner.
The Aboriginal Justice Caucus (AJC) determined that this recommendation was implemented through the Coroner’s Act 2008 (Vic) which legally requires that:
The responsible person must report the death of a person placed in custody or care without delay to a coroner or the Institute.
The Act also requires any person who believes that a reportable death has not been reported to do so ‘without delay’ to a coroner, the Victorian Institute of Forensic Medicine or police.
These legal obligations are reflected in the Victoria Police Manual and Commissioner’s Requirements issued by Corrections Victoria. The AJC considered this recommendation was complete.
This is all currently in practice…so it would be complete.
(Chris Harrison, Co-chairperson, AJC)
Priority for Further Work:
Low
Relevance and potential impact | |||||
|---|---|---|---|---|---|
Low (0-2) | Moderate (3-4) | High (5-6) | |||
Extent of action taken and evidence of outcomes | High (5-6) | ||||
Moderate (3-4) | |||||
Low (0-2) | |||||
Background
The Royal Commission into Aboriginal Deaths in Custody highlighted the urgent need for a uniform legal requirement for custodial authorities to immediately notify the Coroner’s Office of any deaths in custody. This was to ensure timely and thorough investigations and promote greater transparency and accountability. The Commission also recommended that the deceased’s nominated family member and relevant legal services be promptly informed.
Actions Taken Since Last Review
Coroners Act 2008 (Vic)
The Coroners Act 2008 (Vic) obligates custodial authorities to report deaths in custody ‘without delay’ to a coroner or the Victorian Institute for Forensic Medicine (VIFM) which operates the Coronial Admissions and Enquiries office. It also obligates anyone with reasonable grounds to believe a reportable death has not been reported to immediately notify a coroner, the VIFM or police. These legal obligations are reflected in the Victoria Police Manual and Commissioner’s Requirements issued by Corrections Victoria.
Victoria Police
When police attend a death, they need to preserve the scene, notify the coroner if it is a reportable or reviewable death, notify relevant investigators, external authorities, relatives and other relevant people, and facilitate the verification of death by a medical practitioner or other health professional.
Corrections Victoria
Corrections Victoria noted that when emergency services attend a death in custody, it is Victoria Police that notify the coroner.
In 2022 the Department of Justice and Community Safety released the Communications Protocol – Passings in Custody. This protocol confirms roles, responsibilities and agreed steps for communication and notification of all deaths that occur in prison custody. The protocol is updated regularly, with a June 2024 copy supplied for this project.
Impact
Outputs
The Coroners Act 2008 (Vic) obligates custodial authorities to report deaths in custody ‘without delay’ to a coroner. These legal obligations are reflected in Victoria Police guidelines, requirements issued by the Corrections Commissioner, and departmental protocols:
- Victoria Police Manual Guidelines – Deceased Persons
- Commissioner’s Requirement - Reporting and Review of Deaths in Prison
- Commissioner’s Requirement – Incident Reporting
- Communication Protocol – Passings in Custody.
Outcomes
The Coroners Act 2008 (Vic) obligates custodial authorities to report deaths in custody ‘without delay’ to a coroner or the Victorian Institute for Forensic Medicine (VIFM) which operates the Coronial Admissions and Enquiries office. It also obligates anyone with reasonable grounds to believe a reportable death has not been reported to immediately notify a coroner, the VIFM or police. These legal obligations are reflected in the Victoria Police Manual and Commissioner’s Requirements issued by Corrections Victoria.
Community Views
Aboriginal Justice Caucus
The AJC found there was a clear legal requirement for custodial authorities to report deaths in custody to the coroner without delay, and
it’s pretty well standard procedure.