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18
Coroner to make recommendations to the Attorney-General
That the State Coroner, in reporting to the Attorney-General or Minister for Justice, be empowered to make such recommendations as the State Coroner deems fit with respect to the prevention of deaths in custody.
Aboriginal Justice Caucus Assessment
Recommendation 18 intended for the State Coroner to have the authority to make any recommendations they consider appropriate regarding the prevention of deaths in custody when reporting to the Attorney-General or Minister for Justice.
Actions taken partially align with the intent of this recommendation. The Coroners Act 2008 (Vic) empowers coroners to make recommendations on ‘any matter’ they have investigated in relation to a death in custody including ‘public health and safety or the administration of justice’. All coroners can report to the Attorney-General on a death which they have investigated.
The Coronial Council of Victoria, of which the State Coroner is a member, is required to provide advice and make recommendations to the Attorney-General including on ‘matters relating to the preventative role played by the Coroners Court’. The Council can provide advice and recommendations ‘of its own motion’ or at the request of the Attorney-General.
Acknowledging recommendations made to the Attorney-General from inquests into Aboriginal deaths in custody, and the advice and recommendations of the Coronial Council, we remain extremely concerned about the lack of action in response to these recommendations.
I don’t think it goes far enough in terms of implementing the recommendations.
(Merle Miller, VAEAI)
Given limited evidence of tangible outcomes, we continue to advocate for independent oversight of the implementation of coronial recommendations and others to prevent deaths in custody.
We need to make a very, very strong statement about how dissatisfied we are with what’s happened so far and that we hope that the Aboriginal Social Justice Commissioner could be put in place to provide oversight for these sorts of things so that there is actually some action taken once the recommendations come from the coroner. They don’t just make these recommendations for the sake of doing it; they are there for a reason. One would think that the government should take note of that, be responsible and act. But unfortunately, they don’t.
(Marion Hansen, Chairperson, AJC and Chairperson, Southern Metro RAJAC)
Recommendation 18 remains relevant. Stronger legislative provisions would strengthen the prevention role of the Coroners Court and support implementation of recommendations made by coroners and the Coronial Council of Victoria.
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 the preventative role of the Coroners Court and Coronial Council of Victoria and support implementation of their recommendations.
Government response to the advice and recommendations of the Coronial Council of Victoria
Ensure government responds to the advice and recommendations of the Coronial Council of Victoria with public statements of intent, meaningful action and funded solutions.
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. The mandate of the Commissioner should include monitoring of Royal Commission recommendations that impact Aboriginal people (including RCIADIC recommendations), as well as coronial recommendations and others to prevent Aboriginal deaths.
National repository of publicly available information on coronial recommendations
Commonwealth Government to establish a publicly accessible repository of coronial recommendations in collaboration with State and Territory Governments.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) made several recommendations to strengthen the role of the State Coroner in preventing deaths in custody. Building on Recommendation 16 which sought to empower the State Coroner to seek additional information about the implementation of coronial recommendations, Recommendation 18 advocated for the State Coroner to be able to identify broader, recurring issues that may not be apparent when looking at individual cases in isolation. Ultimately, this recommendation aimed to empower the State Coroner to contribute systemic insights and recommendations to help prevent future deaths in custody.
Actions Taken Since Last Review
Coroners Court of Victoria
Recommendations are made where, following an investigation into a reportable death or fire, a coroner has identified systemic issues or other learnings that can help prevent similar incidents occurring in the future.
Coronial recommendations are rigorously prepared to ensure they are informed by and based
on the evidence before the Court. If a coroner determines that the care and circumstances relating to an incident were handled appropriately by the parties involved, or that existing failures have since been adequately addressed, or that no prevention opportunities can be identified relating to that death, recommendations will not be made.
Where prevention opportunities are identified, the coroner will direct 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.
When developing coronial recommendations, coroners draw on a range of resources including the Coroners Prevention Unit (CPU), medical registrars, external agencies and independent experts.
Coroners Prevention Unit
The CPU was established within the Court’s administrative arm to assist coroners in identifying opportunities to strengthen public health and safety through well-researched, evidence-based recommendations. It is the only multidisciplinary team of its kind in Australia, comprising specialist staff who work to identify any potential failures and other factors that contributed to the incident. Coroners can refer matters to the CPU at any point during an investigation.
Additionally, the CPU supports coronial investigations by undertaking both individual and collaborative research projects aimed at developing a better understanding of the circumstances in which deaths occur in Victoria to identify new prevention opportunities. Throughout the 2023–24 reporting period, coroners made 548 referrals to the CPU about deaths under investigation. The advice coroners sought input on, included:
- the circumstances in which the death occurred, including factors that may have contributed to the fatal incident
- the frequency of previous and subsequent similar deaths in Victoria, including recurring themes and shared features
- interventions that have been proved or are suspected to reduce the risk that similar deaths will occur in future
- regulations, standards, codes of practice or guidelines that might be relevant to the circumstances in which the death occurred
- insights gleaned from previous coronial investigations into similar deaths, including past recommendations
- feasible, evidence-based recommendations for prevention opportunities which the coroner can consider in finalising the investigation.
Coronial Council of Victoria
The Coronial Council of Victoria (the Council) was established under the Coroners Act 2008 (Vic) as the first body of its kind in Australia. It is independent from the Victorian Government and the Coroners Court. The Council's role is to advise and make recommendations to the Attorney-General, including on issues of importance to Victoria's coronial system, matters relating to the preventative role played by the Coroners Court and the way in which the coronial system engages with families and respects their cultural diversity.
The Council is required to act in a way that:
- does not impinge on the independence of coroners’ professional tasks or the jurisdiction of the State Coroner
- delivers strategic advice reflecting the changing physical and social environment with the aim of promoting a modern and responsive coronial system
- strengthens collaboration between agencies across the service system
- focuses on advice to enhance services to families
- promotes the prevention role of the coroner
- ensures that the views of bereaved families are reflected in the development of advice
- complements existing governance structures in the State coronial system, and
- promotes transparency, accessibility and accountability regarding the functions of the Victorian coronial system.
Membership of the Council is set out in section 111 of the Coroners Act 2008 (Vic). There are three statutory members: the State Coroner, the Director of the Victorian Institute of Forensic Medicine and the Chief Commissioner of Police. The Council can have an additional five to seven members appointed by the Governor in Council on recommendation by the Attorney-General. These members are chosen based on merit and the diversity of experience they bring to the role.
The Council is supported by a Secretariat, provided by the Department of Justice and Community Safety.
Impact
Outputs
The Coroners Act 2008 (Vic) empowers coroners to make recommendations on ‘any matter’ they have investigated in relation to a death in custody including ‘public health and safety or the administration of justice’. All coroners can report to the Attorney-General on a death which they have investigated.
The Act establishes the Coronial Council of Victoria and the State Coroner as a member. The Council is required to provide advice and make recommendations to the Attorney-General including on ‘matters relating to the preventative role played by the Coroners Court’. The Council can provide advice and recommendations ‘of its own motion’ or at the request of the Attorney-General.
Outcomes
The Coroners Act 2008 (Vic) explicitly recognises death prevention as a coronial function. One of the purposes of the Act is ‘to contribute to the reduction of the number of preventable deaths’ through the findings of the investigations of these deaths and ‘the making of recommendations, by coroners. In the last six coronial inquests into Aboriginal deaths in custody, recommendations were made to the Attorney-General or Minister for Justice on two occasions, from the inquests into the passing of Tanya Day and Veronica Nelson.
One of the functions of the Council is to prepare advice and make recommendations to the Attorney-General on ’matters relating to the preventative role played by the Coroners Court’ through ‘own motion’ reviews or ‘references’ in response to Attorney-General requests. There have been a total of nine references and own motion reviews completed by the Council. None of these focused on the prevention of deaths in custody. Government responses or statements of support were only provided in response to two of these, most recently in 2021.
Community Views
Victorian Aboriginal Legal Service
The Victorian Aboriginal Legal Service (VALS) emphasised the coronial process's pivotal role in driving systemic change to prevent future deaths. VALS highlighted bereaved families' frustration over the lack of accountability in implementing coronial recommendations, which serve as a critical avenue for Aboriginal communities to influence systemic reforms.
VALS recommended that:
- The Department of Premier and Cabinet should oversee the implementation of coronial recommendations by relevant departments and agencies.
- Government responses to coronial recommendations should detail actions being taken and be tabled in Parliament.
- An independent, adequately funded Aboriginal and Torres Strait Islander Social Justice Commissioner should be established to monitor the implementation of RCIADIC and coronial inquest recommendations.
- The Commonwealth Government should establish a central database of publicly available coronial recommendations in collaboration with State and Territory Governments.