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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
16
Coroner to call for further information on recommendations
That the relevant Ministers of the Crown to whom responses are delivered by agencies or departments, as provided for in Recommendation 15, provide copies of each such response to all parties who appeared before the Coroner at the inquest, to the Coroner who conducted the inquest and to the State Coroner. That the State Coroner be empowered to call for such further explanations or information as he or she considers necessary, including reports as to further action taken in relation to the recommendations.
Aboriginal Justice Caucus Assessment
Recommendation 16 aimed to ensure all parties involved in an inquest are informed of actions taken in response to recommendations, and to enable the State Coroner to call for further information on these.
The Aboriginal Justice Caucus (AJC) found that while current practices under the Coroners Act 2008 (Vic) partially align with this intent, significant gaps remain. Agencies must respond to coronial recommendations within three months, and these responses are published on the Coroners Court of Victoria website. Since 2021, the Court has also published Recommendations Reports that compile recommendations, and the status of agency responses.
There need to be more processes set up, getting information about the implementation of coronial recommendations shouldn't be ad hoc. There needs to be an open process with the coroner able to ask for additional information. It is dependent on the coroner and what they are willing to take on...there needs to be someone over the coroner who can hold that accountability.
(Chris Harrison, Co-chairperson, AJC)
There’s less evidence of the intended outcomes of this recommendation as there are no formal processes in place for monitoring or following up on agency responses, especially those marked as 'Not Accepted', 'Overdue', or 'Partially Accepted'. Even for recommendations ‘Accepted in Full’, there is limited information available on actions, if any, taken to implement them, and rarely is any information provided after the initial response.
The scope needs to be changed to begin with. Start with a wider scope looking at a broader range of issues. The sky's the limit, not the limit's the system.
(Chris Harrison, Co-chairperson, AJC)
Priority for Further Work:
Moderate
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 (Vic)
Empower the State Coroner to call for further explanation and information on action taken in response to coronial recommendations.
Establish a process for providing regular updates on implementation of coronial recommendations
Establish a formal process to provide regular updates to families and the broader community on action taken to implement coronial recommendations.
Independent oversight - Aboriginal Social Justice Commissioner
Establish a well-resourced, independent office of the Aboriginal Social Justice Commissioner to strengthen oversight and accountability for Aboriginal justice outcomes. This office should be properly funded and report directly to the Parliament. The mandate of the Commissioner should include monitoring of Royal Commission recommendations that impact Aboriginal people (including RCIADIC recommendations), as well as recommendations from coronial inquests into Aboriginal deaths.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) highlighted the crucial role of coronial recommendations in addressing systemic problems and preventing future deaths. However, it also identified an absence of mechanisms to ensure these recommendations are acted upon. The RCIADIC recommended that government departments and agencies should provide detailed responses outlining actions taken or proposed in response to coronial recommendations. These responses should be shared with all parties involved in the inquest, and the State Coroner to foster a transparent exchange of information and promote public accountability. Critically, the Commission advocated for the State Coroner to be empowered to call for further information on action taken in response to a coroner’s recommendation.
Actions Taken Since Last Review
Coroners 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 can make recommendations to any relevant minister, public statutory authority or entity. Any matter connected with a death may be included, such as recommendations relating to 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 to the coroner, 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.
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 specifying what action, if any, has or will be taken in relation to those recommendations. Responses are typically provided directly to the coroner that made the recommendations by the responsible agency or department not the ‘Minister of the Crown’ as specified in recommendations 15 and 16.
The Coroners Court publishes these responses on their website and summarises them in their Coroners Court of Victoria Recommendations Reports. These reports collate all recommendations made in a twelve-month period and categorise the status of responses as ‘Accepted in full’, ‘Accepted in part’, ‘Alternative adopted’, ‘Rejected in full’, ‘Under consideration’ or ‘Overdue’.
Outcomes
Some aspects of Recommendation 16 are reflected in the Coroners Act 2008 (Vic), such as the requirement for agencies to respond to coronial recommendations within three months and the online publication of these responses. However, the Act does not empower the State Coroner to ‘call for such further explanations or information as he or she considers necessary, including reports as to further action taken in relation to the recommendations.’
There are no formal processes in place for monitoring or following up on agency responses, especially those marked as 'Not Accepted', 'Overdue', or 'Partially Accepted'. Even for recommendations ‘Accepted in Full’, there is limited information available on actions, if any, taken to implement them.
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.