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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
15
Respond to coronial findings within three months of publication
That within three calendar months of publication of the findings and recommendations of the Coroner as to any death in custody, any agency or department to which a copy of the findings and recommendations has been delivered by the Coroner shall provide, in writing, to the Minister of the Crown with responsibility for that agency or department, its response to the findings and recommendations, which should include a report as to whether any action has been taken or is proposed to be taken with respect to any person.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 15 was to ensure relevant agencies and departments report their responses to coronial recommendations to their Ministers within three months of publication of the findings.
The Aboriginal Justice Caucus (AJC) considered that requirements in the Coroners Act 2008 (Vic) reflect the intent of Recommendation 15 as entities in receipt of recommendations from a coroner must respond in writing within three months. Their response must specify what action, if any, has or will be taken in relation to the recommendations made by the coroner.
Publication of these responses on the Coroners Court of Victoria website, and summaries of them in Coroners Court of Victoria Recommendations Reports, provided clear evidence of the implementation of this recommendation.
However, the AJC considered that the legislation could be strengthened to support compliance with the Coroners Act 2008 (Vic) and ensure all parties in receipt of coronial recommendations are required to respond and ultimately act on those recommendations.
If the recommendations were implemented, I'd feel a bit more comfortable about saying yes, it would improve, but not as it stands at the moment. Just because the recommendations are put forward by the coroner, there's no guarantee that they're going to be implemented or accepted by the government of the day.
(Chris Harrison, Co-chairperson, AJC)
To address accountability gaps, the AJC continues to advocate for an independent, statutory office of the Aboriginal Social Justice Commissioner to monitor the implementation of RCIADIC recommendations and coronial recommendations arising from Aboriginal deaths in custody.
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) | |||||
Potential Actions for Further Work
Victorian Aboriginal Social Justice Commissioner
The Victorian Government should establish an independent, statutory office of the Aboriginal Social Justice Commissioner. This office should be properly funded and report directly to the Parliament. The mandate of the Commissioner should include monitoring the implementation of RCIADIC recommendations, as well as recommendations from coronial inquests into Aboriginal deaths.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) highlighted the importance of ensuring that coronial recommendations were addressed. To enhance transparency and accountability, the Commission advocated for responsible agencies to report within three months of findings being made. Their responses were to indicate whether any actions had been taken or proposed in line with coronial recommendations.
Actions Taken Since Last Review
Coroner’s Court of Victoria
Throughout their investigations, coroners seek to identify if the event was preventable and make recommendations to stop similar incidents happening in the future. Where prevention measures are found, a coroner will make recommendations to any relevant minister, public statutory authority or entity. Any matter connected with a death may be included, such as public health and safety or the administration of justice. A coroner may also report to the Attorney-General in relation to a death or fire they have investigated.
Any public statutory authority or entity to whom a recommendation is directed must respond, in writing, within three months stating what action, if any, has or will be taken. The Court publishes all responses to recommendations on coronerscourt.vic.gov.au.
The Coroners Court of Victoria Recommendations Report is a regular publication collating all recommendations made in a twelve-month period and the status of responses.
Impact
Outputs
Under the Coroners Act 2008 (Vic) any public statutory authority or entity that receives recommendations made by a coroner must provide a written response within three months of receiving them. Their response must specify what action, if any, has or will be taken in relation to the recommendations made by the coroner. The Coroners Court of Victoria publishes these responses on their website and summarises them in their Coroners Court of Victoria Recommendations Reports.
Outcomes
While entities are legally required to provide a written response to coronial recommendations within three months of receiving them, the Coroners Act 2008 (Vic) does not outline any enforcement powers, or penalties to promote compliance.
Responses are typically provided directly to the coroner that made the recommendations by the responsible agency or department not the ‘Minister of the Crown with responsibility for that agency or department’ as specified in Recommendation 15.
The eighth edition (current at the time of writing) of the Coroners Court of Victoria Recommendation Report covered the period from 1 September 2023 to 31 December 2024. During this period, coroners made 43 recommendations across 9 findings related to deaths in custody (including two Aboriginal men who passed in prison). Following these recommendations, the Court received:
- 44 responses stating the recommendation was accepted in full.
- 9 responses stating the recommendation was accepted in part or an alternative was proposed.
- 3 responses stating the recommendation remains under consideration.
- 1 response where the recommendation was not accepted.
In addition to these:
- 8 responses had not been received within the required time frame (overdue).
While these reports enable closer scrutiny of responses to coronial recommendations, particularly those that are overdue, there remain limitations as acceptance of a recommendation does not guarantee any action will be taken in response.
Community Views
Victorian Aboriginal Legal Service
The Victorian Aboriginal Legal Service (VALS) proposed various measures to strengthen responses to coronial recommendations and their monitoring and oversight, including that:
- Government responses to coronial recommendations detail the action being taken to implement the recommendation and the response should be tabled in Parliament.
- An independent statutory body be established to oversee the Government's implementation of coronial recommendations. VALS argue that this role would be best served by an Aboriginal Social Justice Commissioner, a role originally identified in the 2005 Review. This Commissioner would require sufficient powers and resources to effectively monitor implementation, including overseeing recommendations from the RCIADIC and other coronial recommendations.
- The Commonwealth Government should work with State and Territory Governments to establish a central database of publicly available coronial recommendations.