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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
24
Inform family of progress of investigation and brief
That unless the State Coroner or the Coroner appointed to conduct the inquiry otherwise directs, investigators conducting inquiries on behalf of the Coroner and the staff of the Coroner’s Office should at all times endeavour to provide such information as is sought by the family of the deceased, the Aboriginal Legal Service and/or lawyers representing the family as to the progress of their investigation and the preparation of the brief for the inquest. All efforts should be made to provide frank and helpful advice and to do so in a polite and considerate manner. If requested, all efforts should be made to allow family members or their representatives the opportunity to inspect the scene of death.
Although the KEU plays a critical role in explaining the coronial process to Aboriginal families and providing information and updates throughout the process, there is a clear need for better processes to ensure that families and their legal representatives are provided with detailed information throughout the entire coronial process.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 24 was to provide information surrounding inquests, investigations, and their progress to families or their legal representatives.
The Coroners Court of Victoria has implemented measures under the Coroners Act 2008 (Vic) and Practice Direction 6 of 2020 to keep families and their legal representatives informed and engaged throughout the coronial process. Coroners and court staff are encouraged to provide information to, and update families on the progress of investigations and facilitate contact with legal services like the Victorian Aboriginal Legal Service (VALS) that may also assist in this regard.
Community feedback and insights from VALS indicate that families continue to encounter challenges with receiving timely information updates, particularly on the status and content of coronial briefs. If the brief is delayed, families are not informed and must request their legal representative follow up with the Coroners Court to receive an update.
There is a clear need for better processes to ensure that families and their legal representatives are provided with detailed information throughout the entire coronial process. (VALS)
There are no Coroners Court, Corrections Victoria or Victoria Police directives or procedures to assist with facilitating family requests to inspect the scene of death.
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
Timeline for coronial processes
Coroners Court of Victoria to set timeframes for coronial processes in practice directions to provide better support for families and timeliness in the process. Update procedures to ensure that families and their legal representatives receive regular updates about the coronial brief.
Amend Practice Direction 7 of 2014 (‘Coronial Briefs’)
Require coroners to set a deadline for preparation of the coronial brief and require the coronial investigator to provide written reasons to the family and interested parties if the deadline is not met.
Enable families or their legal representatives to inspect the scene of death
Introduce explicit legal provisions for families or their legal representative to inspect the scene of death.
Coroners Court, Corrections Victoria and Victoria Police to update their respective directives and procedures to assist with facilitating family requests to inspect the scene of death.
As outlined for recommendations 21 and 22:
Additional resourcing for Aboriginal Engagement Unit within the Coroners Court
Provide additional resources to the Yirramboi Murrup Unit to better support families with coronial processes.
Coroners Court call-over list for Aboriginal passings
Establish a monthly call-over list for all matters being dealt with by the Court when an Aboriginal person has passed away. The purpose of this list would be to provide regular updates to bereaved families and other interested parties about the progress of the investigation/inquest.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) stressed the importance of clear, respectful, and transparent communication throughout the investigation of deaths in custody. It underscored the need for investigators and Coroner’s Office staff to respond appropriately to requests from the deceased’s family or their representatives. This included providing updates on the progress of the coronial investigation, offering courteous and supportive guidance, and allowing the family or their representatives to view the scene of death to help address any concerns about the circumstances surrounding their loved one’s passing.
Actions Taken Since Last Review
Coroners Court of Victoria
Since its establishment in 2019, the Coroners Koori Engagement Unit (now the Yirramboi Murrup Unit) has assisted Aboriginal families navigating the coronial process by providing culturally responsive support and improving the cultural sensitivity of investigations and court proceedings.
The Unit consists of Aboriginal people employed by the Coroners Court to provide cultural support and communicate directly with Aboriginal families throughout the coronial process. They facilitate family meetings and access to hearings, including participation via technological means, and assist with arrangements for families to attend court when needed.
The State Coroner issued a new practice direction in 2020 outlining protocols for the conduct of coronial investigations into Aboriginal deaths in custody. Under this practice direction, the family of the deceased are to be kept informed of the progress of the investigation, including being consulted on proposed hearing and inquest dates.
This practice direction gives Aboriginal people a voice in investigations into deaths in custody and ensures the Court is equipped with the cultural competency to support them.
Victoria Police
In the Victoria Police Manual sections on ‘Deceased Persons’ and ‘Death or Serious Injury Incidents Involving Police, there is no mention of family members or their legal representatives being given the opportunity to inspect the scene of death as outlined in this recommendation.
Impact
Outputs
The Coroners Act 2008 (Vic) and Practice Direction 6 of 2020 support the intent of keeping families updated on the progress of investigations and preparation of the coronial brief. The Act requires families to be kept informed about the progress of the investigation, while Practice Direction 6 supports ongoing engagement and regular communication with families.
Outcomes
The requirements of the Coroners Act 2008 (Vic), Practice Direction 6, and the practice of the Coroners Koori Engagement Unit suggest that families are routinely contacted and engaged throughout the coronial process.
However, community concerns expressed by VALS highlight that limited information is provided to family members during the investigation, which can take several years.
A lack of information during this time further exacerbates the distrust that Aboriginal families may have in the process.
Where matters proceed to inquest, families are often not provided with clear information about the timeframes for the inquest and when the coronial brief will be provided. These information barriers may impact families' ability to attend hearings, remain informed, and fully engage with the investigation into their loved one’s passing.
There are no Coroners Court, Corrections Victoria or Victoria Police directives or procedures to assist with facilitating family requests to inspect the scene of death.
Community Views
Victorian Aboriginal Legal Service
The Coronial Council of Victoria completed a Review into Improving the Experiences of Bereaved Families with the Coronial Process. In their 2021 submission to this review, VALS acknowledged the importance of the Coroners Koori Engagement Unit (KEU):
The support provided by KEU has been instrumental for Aboriginal families. The KEU has also enhanced the capacity of VALS to represent our clients, by liaising closely with VALS lawyers in relation to all aspects of the coronial process. We strongly support the KEU being further embedded in the Court, with increased visibility over the coronial investigation and access to all information that is relevant for families in a timely manner.
Clear communication and timely access to information throughout the coronial process are essential to ensure that Aboriginal families who have lost a loved one are treated with dignity, respect, and cultural sensitivity. Early and consistent information helps alleviate grief and distress, allowing families to participate meaningfully in investigation and inquest processes.
Although the KEU plays a critical role in explaining the coronial process to Aboriginal families and providing information and updates throughout the process, there is a clear need for better processes to ensure that families and their legal representatives are provided with detailed information throughout the entire coronial process.
While recognising that the Coroners Act 2008 and Practice Direction 6 seek to uphold RCIADIC recommendations 21, 22 and 24 (among others), VALS noted that in practice Aboriginal families often face communication gaps and serious delays. Investigations can take years, with little information shared during this time, deepening existing distrust in the coronial system. If a case does not go to inquest, families are usually notified only via written correspondence. For those that do proceed, families frequently lack clarity on timeframes and do not receive timely access to the coronial brief.
Further challenges arise during the inquest process itself. Families and their legal representatives, such as those from VALS, report delays in receiving critical information, poor communication about key procedural steps, and insufficient responses from the Court. In some cases, decisions by the coroner are not communicated to the family or their representatives, adding to their distress and frustration.
To address these issues, VALS recommend that the Coroners Court:
- Consider options for family conferencing, to provide a culturally appropriate forum for providing regular updates during investigations.
- Establish a monthly call-over list for all matters being dealt with by the Court when an Aboriginal person has passed away. The purpose of this list would be to provide regular updates to bereaved families and other interested parties about the progress of the investigation/inquest.
- Amend Practice Direction 7 of 2014 (‘Coronial Briefs’) to require coroners to set a deadline for preparation of the coronial brief and require the coronial investigator to provide written reasons to the family and interested parties if the deadline is not met.