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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
17
Coroner to report annually on deaths in custody and responses
That the State Coroner be required to report annually in writing to the Attorney-General or Minister for Justice, (such report to be tabled in Parliament), as to deaths in custody generally within the jurisdiction and, in particular, as to findings and recommendations made by Coroners pursuant to the terms of Recommendation 13 above and as to the responses to such findings and recommendations provided pursuant to the terms of Recommendation 16 above.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 17 was to require the State Coroner to report annually on deaths in custody to Parliament, including findings, recommendations and responses to them.
In accordance with the Coroners Act 2008 (Vic) the State Coroner is required to submit an annual report to the Attorney-General by October 31st each year, and the Attorney-General must present it to Parliament within seven sitting days. The Act requires these reports to contain ‘a review of the operation of the Coroners Court’ rather than the more specific elements outlined in Recommendation 17.
Annual reports for the Coroners Court of Victoria are submitted to the Attorney-General and tabled in parliament each year. These provide some information on deaths in custody, but less on recommendations aimed at preventing further custodial deaths, as per Recommendation 13. Additionally, the RCIADIC stressed that these reports should include information on responses to findings and recommendations, as per Recommendation 16. The Coroners Court of Victoria Recommendations Reports do this to a degree, but often the responses are brief statements about intentions. There is little information on whether these intentions resulted in meaningful action or the full implementation of recommended measures.
With their reporting and so forth, I think it should be out there and available for Caucus to see what's happening for our people…because not much has happened...we need information on any measures taken to improve things.
(Zeta Thomson, Aboriginal Independent Prison Visitor)
While Recommendation 17 remains relevant, the Aboriginal Justice Caucus believe greater oversight and accountability for implementation of coronial recommendations is of paramount importance for further work.
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)
- Strengthen legal provisions so that authorities are compelled to act on coronial recommendations.
- 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
- Set up mechanisms for ongoing monitoring and public reporting on the progress of implementing recommendations. This could include regular updates to a central database accessible to the public.
- 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.
Evaluation and Feedback
Implement a system for evaluating the impact of recommendations once they are implemented. Collect feedback from Community and stakeholders to assess whether changes have the desired effect and adjust as needed.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) highlighted the importance of strong oversight and accountability in addressing deaths in custody. It stressed the critical role of coronial recommendations in identifying systemic issues and preventing future fatalities. To support the effective implementation of these recommendations, the Commission proposed the creation of monitoring and accountability mechanisms—such as mandating the State Coroner to provide an annual report on deaths in custody and the corresponding actions taken.
Actions Taken Since Last Review
Coroners Court of Victoria
The Coroners Act 2008 (Vic) requires the State Coroner to provide an annual report of the operation of the Coroners Court to the Attorney-General. It is then tabled in Parliament.
These are available via the publications section of the Coroners Court website at www.coronerscourt.vic.gov.au.
Typically, these reports include information about the Coroners Court, its strategic directions, achievements and coroners. The work of the Court is summarised across several sections on ‘investigations into deaths and fires’, ‘reducing preventable deaths’, ‘promoting public health and safety’, and ‘corporate governance and support’ which include tables summarising outputs like the number of recommendations made and case studies featuring particular coronial inquiries or inquests.
The number of recommendations made each year is dependent on the matters before the coroners and associated opportunities for prevention. The Court’s focus is on providing robust, evidence-based investigations to help protect the Victorian community against preventable deaths. Any agency or person who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken. The Court also publishes a bi-annual report collating all recommendations over a 12-month period and the status of responses received.
Impact
Outputs
Under the Coroners Act 2008 (Vic), the State Coroner must submit an annual report to the Attorney-General by 31 October, which is then tabled in Parliament.
The Coroners Court of Victoria also publishes Recommendations Reports on their website that summarise the status of agency responses to coronial recommendations.
Outcomes
The Coroners Act 2008 (Vic) requires the State Coroner to submit an annual report to the Attorney-General by 31 October each year. The Attorney-General must table the report in Parliament. Neither the Act nor the Coroners Regulations 2019 specify the required content for these annual reports, so it is at the discretion of the State Coroner and management of the Coroners Court. Typically, the information provided is a summary across many of the court’s functions, investigations and recommendations, not just those related to deaths in custody.
The Court also publishes a bi-annual report collating all recommendations over a 12-month period and the status of responses received. These are made publicly available but there is no legislative requirement for them to be provided to the Attorney-General or tabled in parliament.
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.