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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
11
Formal coronial inquest for all deaths in custody (required by law)
That all deaths in custody be required by law to be the subject of a coronial inquiry which culminates in a formal inquest conducted by a Coroner into the circumstances of the death. Unless there are compelling reasons to justify a different approach, the inquest should be conducted in public hearings. A full record of the evidence should be taken at the inquest and retained.
Coronial investigations into Aboriginal deaths in custody are currently mandatory, but Coronial Inquests are not. Indeed, in cases where internal reviews list the cause of deaths as being from natural causes, there is currently no requirement for that to be tested, despite the fact that many deaths in custody are due to poor healthcare in prisons. Indeed, for this reason, the Coronial Inquest into the passing of Veronica Nelson almost never happened.
. . .Coronial Inquests should be mandatory for all Aboriginal deaths in custody, regardless of the suspected circumstances, and investigations must be carried out by a specialist civilian investigation team that is independent from police and developed by Aboriginal communities. This team must have the same coercive powers as the police for conducting these investigations.
Aboriginal Justice Caucus Assessment
Recommendation 11 intended for governments to legally require a coronial inquest for all deaths in custody, with the inquest conducted in public hearings and a full record of evidence kept.
The Aboriginal Justice Caucus (AJC) determined that action taken partially aligned with this intent. The Coroners Act 2008 (Vic) mandates that a coroner must investigate a death in custody, but they can decide whether an inquest is necessary where a medical investigator finds the death was due to natural causes.
There are issues with forensic examiners suggesting that deaths are caused by 'natural causes'…there are a lot of contributing causes that should be looked into in terms of health perspectives where the cause of young people passing away in custody is deemed to be by 'natural causes'.
(Samantha Rudolph, VACCHO)
The AJC found some evidence of outcomes as the Coroners Act 2008 requires that all deaths in custody must be investigated, but conducting a formal inquest is not mandatory. Under Practice Direction 6 of 2020 – Indigenous Deaths in Custody, where a family requests an inquest, the investigating coroner is to ‘have regard to RCIADIC Recommendation 11 even where a death in custody is due to natural causes.’
Inquests are typically held in public unless compelling reasons exist to exclude individuals. All evidence presented during the inquest must be recorded, ensuring a complete record of proceedings.
Recommendation 11 remains highly relevant. Further work to implement this recommendation could contribute to improving conditions and care in custody and preventing Aboriginal deaths.
Further work must be required for any Aboriginal death in custody, and a formal inquest must be legislated. Subsequent cases must be a priority for inquest and go ahead within two years, which should also be put into the Act. If there is negligence around health and medical care, there needs to be some sort of prosecution for the parties involved. The Coroners Court must reinvestigate deaths in custody prior to 2020 that were deemed due to natural causes.
(Chris Harrison, Co-Chairperson, AJC)
Priority for Further Work:
High
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) | |||||
Potential Actions for Further Work
Amend the Coroners Act 2008
- Legally require a coronial inquest for all Aboriginal deaths in custody, regardless of whether the cause of death is attributed to ‘natural causes’.
- Require coronial inquests into Aboriginal deaths in custody to be completed within two years.
Coronial inquiry into the cluster of Aboriginal deaths in custody considered to be due to ‘natural causes’
Conduct a coronial inquiry culminating in formal inquest for the cluster of Aboriginal deaths in custody attributed to ‘natural causes’ between 2016 and 2019. No formal inquests were held into the deaths of these 7 Aboriginal men that occurred across three prisons.
Cultural training for people involved in coronial investigations
Ensure that everyone involved in the investigative process undergoes cultural training and integrates awareness of the RCIADIC recommendations into their work, not just attending training sessions but actively demonstrating this knowledge in their roles and findings.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) recommended conducting formal coronial inquests for every death occurring in custody to guarantee investigations are both rigorous and unbiased. Retaining a full record of the evidence was considered vital to identifying risks and implementing measures to prevent similar fatalities in the future.
Actions Taken Since Last Review
Coroners Court of Victoria
The Coroners Court Bench Book guides Victorian coroners in applying the Coroners Act 2008, outlining established practices across jurisdiction, fairness, and investigations. It includes a section on the RCIADIC, summarising key criticisms and recommendations to improve coronial processes.
The 2023 version of the Coroners Court Bench Book clarifies that inquests are mandatory for deaths in custody or care, unless a coroner, based on a medical report, determines the death was from natural causes. In such cases, no public hearing is held, and findings are based on paperwork. For non-mandatory inquests, coroners may still decide to proceed based on medical evidence, witness statements, or family consultations. A mention hearing may be held, allowing families to make submissions.
Under Section 52 of the Coroners Act 2008 (Vic), any person can request an inquest, and the coroner must respond to their request within three months. When the death involves an Aboriginal person in custody, coroners must consider RCIADIC Recommendation 11. This is outlined in Practice Direction 6 – Indigenous Deaths in Custody issued by the State Coroner:
…where an inquest is requested by family, the investigating coroner will have regard to RCIADIC Recommendation 11 even where a death in custody is due to natural causes.
Impact
Outputs
Coroners Act 2008 (Vic) and Practice Direction 6 of 2020 – Indigenous Deaths in Custody.
Outcomes
Legal requirement for formal coronial inquest for all deaths in custody
Under the Coroners Act 2008 (Vic) a coroner must investigate the death of a person if it occurred in Victoria, was reportable, occurred within 50 years of being reported and is not being investigated by an interstate coroner.
The coroner has discretion to decide whether an inquest is necessary if a medical examiner consider the death is due to natural causes. This has meant that several Aboriginal deaths in custody that occurred in the last 10 years have not been subject to a formal inquest leaving bereaved families devastated and opportunities for prevention missed.
Aboriginal deaths in Corrections custody where there was no formal inquest, 2014-2020
Since the State Coroner introduced Practice Direction 6 in 2020, where a family requests an inquest for an Aboriginal death in custody, coroners are to have regard to RCIADIC Recommendation 11 even where a death in custody is due to natural causes. While this is an improvement it is insufficient to ensure a coronial inquest is held for all deaths in custody and does not have the legal basis intended by Recommendation 11.
Community Views
Victorian Aboriginal Legal Service
Coronial investigations into Aboriginal deaths in custody are currently mandatory, but Coronial Inquests are not. Indeed, in cases where internal reviews list the cause of deaths as being from natural causes, there is currently no requirement for that to be tested, despite the fact that many deaths in custody are due to poor healthcare in prisons. Indeed, for this reason, the Coronial Inquest into the passing of Veronica Nelson almost never happened.
. . .Coronial Inquests should be mandatory for all Aboriginal deaths in custody, regardless of the suspected circumstances, and investigations must be carried out by a specialist civilian investigation team that is independent from police and developed by Aboriginal communities. This team must have the same coercive powers as the police for conducting these investigations.
Crystal McKinnon & Ali Besiroglu
We must also consider amending the Coroners Act so that every Aboriginal death in custody is examined by a mandatory inquest, without exemption. None of the cover-up would have been exposed had the Coroners Court not decided to examine Nelson’s death by way of an inquest.
. . .An urgent review needs to also be conducted by an external auditor, or indeed, by another royal commission to determine whether misleading reports have previously influenced a coroner’s decision to not hold an inquest.