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This is a RCIADIC recommendation

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14

Provision of coronial findings and recommendations to Ministers

Low Priority

That copies of the findings and recommendations of the Coroner be provided by the Coroner’s Office to all parties who appeared at the inquest, to the Attorney-General or Minister for Justice of the State or Territory in which the inquest was conducted, to the Minister of the Crown with responsibility for the relevant custodial agency or department and to such other persons as the Coroner deems appropriate.

Aboriginal Justice Caucus Assessment

The intent of Recommendation 14 was to ensure thorough distribution of coronial findings and recommendations to all parties who appeared at the inquest, the Attorney-General, all relevant Ministers and organisations involved in a death in custody.

The Aboriginal Justice Caucus (AJC) observed that recent actions from the Coroners Court of Victoria closely align with the intent of Recommendation 14. Under the Coroners Act 2008 (Vic) all coronial findings and recommendations must be published online. Typically, the findings also include a page detailing all recipients that were directly provided a copy including Ministers and/or Secretaries of government departments. Findings are typically distributed to family via the Senior Next of Kin and all parties that were legally represented at the inquest.

The AJC found tangible evidence linking actions taken to outcomes given the accessibility of findings and recommendations on the Coroners Court of Victoria website. However, in some case findings and recommendations appeared directed to heads of agencies like the Chief Commissioner of Police, or Secretary of the Department of Justice and Community Safety, rather than the Ministers they serve.

The AJC considered Recommendation 14 remains relevant as it contributes to maintaining transparency and accountability in relation to coronial findings and recommendation from deaths in custody. However, given the existing legislation and actions taken by the Coroners Court of Victoria in recent years, no actions were identified to progress implementation.

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 (RCIADIC) underscored the importance of accountability in investigating and responding to custodial deaths. It advocated for the thorough dissemination of Coroners' findings and recommendations to affected parties, government authorities, and other relevant stakeholders to promote transparency and support proactive measures aimed at preventing future deaths in custody.

Actions Taken Since Last Review

Coroners Court of Victoria

The Coroners Court of Victoria publishes findings and recommendations online in accordance with the Coroners Act 2008 (Vic) and the court rules. There are separate rules for different types of findings. Findings, comments and recommendations after an inquest must be published, unless otherwise ordered by a coroner. If they arise from an investigation they may be published but this is mandated only if they relate to an investigation into a death due to natural causes, where the person was, immediately before death, in custody or care.

Impact

Outputs

Coroners may report to the Attorney-General and/or make recommendations to any Minister, statutory authority or entity. As part of delivering their findings and recommendations, a coroner can direct that copies be provided to particular individuals or parties.

Outcomes

The Coroners Act 2008 (Vic) mandates the publication of coronial findings and recommendations online. However, it does not require them to be provided to ‘all parties who appeared at the inquest’, the ‘Attorney-General or Minister for Justice’, the Minister ‘with responsibility for the relevant custodial agency’ or to ‘such other persons as the Coroner deems appropriate’, as outlined in Recommendation 14.

Whether coronial findings are provided to any of these parties is at the discretion of the investigating coroner. The table below outlines the different parties to whom coroners ordered findings be provided in the six most recent inquests into Aboriginal deaths in custody.

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© 2025 Aboriginal Justice Caucus.

All rights reserved.