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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
13
Coroner to make recommendations to prevent deaths in custody
That a coroner inquiring into a death in custody be required to make findings as to the matters which the Coroner is required to investigate and to make such recommendations as are deemed appropriate with a view to preventing further custodial deaths. The Coroner should be empowered, further, to make such recommendations on other matters as he or she deems appropriate.
Aboriginal Justice Caucus Assessment
Recommendation 13 was intended to empower coroners to conduct thorough investigations and make broad recommendations to prevent future deaths.
The Coroners Act 2008 (Vic) enables Coroners to contribute to the reduction of preventable deaths and to comment on matters related to public health, safety, and the administration of justice. However, the Aboriginal Justice Caucus (AJC) noted that while these provisions were reflected in legislation and practice directions there was limited evidence of broad findings and recommendations arising from coronial inquests into Aboriginal deaths in custody prior to 2020.
While current measures align with the intent of Recommendation 13, further reform is needed including legislating the requirement for coroners to assess the quality of care, treatment, and supervision of an Aboriginal person prior to their passing in custody. As with Recommendation 12, the AJC advocated for ‘minimum’ scope requirements for investigating Aboriginal deaths in custody that include examining potential breaches of human rights and impact of systemic racism, to ensure greater consistency across coronial inquiries and increased likelihood that systemic issues may be identified and addressed over time.
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
- Amend the Coroners Act 2008 so that coroners are empowered to make recommendations on other matters they deem appropriate.
Actions identified in relation to Recommendation 12 are also relevant to Recommendation 13:
- Enshrine parts of Practice Direction 6 in law. Amend the Coroners Act 2008 so that a coroner must consider, when investigating the circumstances of the death of an Aboriginal person in custody, the quality of care, treatment and supervision prior to death.
- Specify minimum requirements for the scope of inquiry into an Aboriginal death in custody that include the examination of potential breaches of human rights and impact of systemic racism.
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) called for a statutory obligation requiring Coroners to extend their investigations beyond the immediate cause of death. Instead of focusing solely on the final moments, the Commission urged a broader approach—encouraging coroners to examine underlying and systemic factors that contribute to custodial deaths. This recommendation was based on evidence from various jurisdictions where contributing issues, such as substance use and withdrawal complications, were routinely overlooked. Recognising the unique position of coroners to uncover persistent and influential risks, the Commission advocated for empowering them to investigate wider circumstances surrounding each death. By doing so, coroners could play a critical role in identifying patterns and persistent problems and recommending preventative actions to address issues within and beyond the justice system to help save lives.
Actions Taken Since Last Review
Coroners Court of Victoria
The Coroners Court Bench Book emphasises the importance of a coroner’s authority to make findings and recommendations, to achieve the objectives of the Coroners Act 2008 (Vic), including:
To contribute to the reduction of the number of preventable deaths and fires through the findings of the investigation of deaths and fires, and the making of recommendations, by coroners.
Practice Direction 6 of 2020 specifies that when looking into the death of an Aboriginal person in custody, the investigating coroner will consider how well the person was cared for, treated, and supervised before they passed. This process involves instructing the coroner's investigator to gather detailed information, including statements from people who can provide evidence about these aspects.
A coroner possesses the authority to issue recommendations to any Minister, public statutory authority, or entity concerning matters associated with a death investigated by the coroner, which may include suggestions related to public health and safety or the administration of justice.
The Coroners Court Bench Book describes three key steps for crafting effective recommendations: identifying the systemic cause, designing a recommendation capable of addressing that systemic cause, and ensuring the recommendation is practical to implement. The Coroners Prevention Unit supports this process by researching similar cases, past recommendations, and feasibility.
Impact
Outputs
Provisions in the Coroners Act 2008 (Vic) and Practice Direction 6 of 2020 support implementation of Recommendation 13.
Outcomes
The Coroners Act 2008 (Vic) provides that a coroner investigating a death is custody may comment on any matter connected with the death ‘including matters relating to public health and safety or the administration of justice.’
The directive in Practice Direction 6 requiring a coroner to assess the care, treatment, and supervision of an Aboriginal person prior to death supports Recommendation 13 by broadening the scope for findings and recommendations. However, this is not legislated.
The Act allows a coroner to make recommendations to any Minister, public statutory authority or entity on ‘any matter connected with a death’ which the coroner has investigated ‘including recommendations relating to public health and safety or the administration of justice’. This align with the aim of Recommendation 13 for coroners to be empowered ‘to make such recommendations on other matters as he or she deems appropriate’.