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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
37
Post-mortem examinations by specialist forensic pathologist
That all post-mortem examinations of the deceased be conducted by a specialist forensic pathologist wherever possible or, if a specialist forensic pathologist is not available, by a specialist pathologist qualified by experience or training to conduct such post-mortems.
Aboriginal Justice Caucus Assessment
Recommendation 37 calls for all post-mortem examinations to be carried out by specialist forensic pathologists. When a death is reported to the Coroner, forensic pathologists from the Victorian Institute of Forensic Medicine (VIFM) examine the body to understand the cause of death.
An Aboriginal Liaison Officer will speak to families, explain the process, and seek to understand any cultural matters that need to be considered. Usually, a preliminary check is done first to decide whether a full autopsy is needed. If it is, that examination will be led or supervised by a specialist pathologist.
Importantly, every death in custody, including those where an Aboriginal person has passed, must be reviewed by a second specialist pathologist. All VIFM pathologists are certified professionals as members of the Royal College of Pathologists of Australasia.
The new Victorian Institute of Forensic Medicine Act (Vic) recognises the importance of Aboriginal cultural rights. It says that everyone involved in these processes should, as much as possible, respect cultural beliefs, and understand the diverse needs of Aboriginal communities—especially self-determination and connections to family, community, culture, and Country.
To make sure this happens in practice, all VIFM staff need to take part in ongoing training. This includes learning about the Royal Commission into Aboriginal Deaths in Custody, the impacts of stating that a death in custody is due to ‘natural causes’, and cultural practices relating to Aboriginal passings.
We also suggest that pathologists and medical examiners learn more about Aboriginal health and wellbeing, including the social and cultural factors that affect it. This helps ensure that their work is not only medically sound but also culturally responsive and respectful.
Specific training around Aboriginal health determinants and closing the gap and all those other things that impact on Aboriginal health and Aboriginal health and wellbeing outcomes would be really relevant to these forensic pathologists. I'm not sure whether such training exists, but I think it's relevant here, especially with the passings of younger people to chronic health conditions.
(Ebony Hickey, Chairperson, Barwon South West RAJAC)
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
Training for pathologists on determinants of Aboriginal health and the RCIADIC
Ensure all Victorian Institute of Forensic Medicine pathologists are trained on the determinants of Aboriginal health, relevant RCIADIC findings, and the implications for coronial inquests when a death in custody is determined to be due to ‘natural causes’. Training should aim to build capability to enable pathologists to perform their functions in line with the Aboriginal cultural rights principle in the VIFM Act 2024.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) stressed the vital role of post-mortem examinations, such as autopsies, in properly determining how a person died in custody. These medical investigations help identify any injuries, illnesses, or other factors that may have contributed to the death. Getting a clear and accurate picture of the cause of death is essential, not just for justice, but also for the families and communities affected.
The Commission also highlighted that these examinations must be carried out by experts—specifically trained forensic pathologists—to ensure the highest standards. Importantly, the RCIADIC recognised that many Aboriginal families have cultural and spiritual concerns about autopsies. It called for the development of respectful protocols that honour these beliefs while still allowing for a proper investigation. The aim is to strike a balance between cultural respect and the need to uncover the truth.
Actions Taken Since Last Review
Victorian Institute of Forensic Medicine
The objectives of the Victorian Institute of Forensic Medicine (VIFM) include: overseeing and coordinating the provision of forensic services in Victoria; assisting the Coroners Court with its functions under the Coroners Act 2008 (Vic); contributing to public health and safety, the administration of justice and reducing the number of preventable deaths; and contributing to the development of knowledge, practice and innovation in the provision of forensic services.
The new Victorian Institute of Forensic Medicine Act 2024 (Vic) promotes Aboriginal cultural rights by providing that in performing a function or exercising a power, a person should have regard, as far as possible in the circumstances, to respecting the cultural beliefs of persons affected by the events to which the Institute’s services relate, and to recognising the diverse needs of Aboriginal communities, including the importance of self-determination and connection to culture, family, community and Country.
In Victoria, a preliminary examination is usually performed by a forensic pathologist to inform a decision on whether an autopsy is required. This procedure may include: a visual examination; collection and review of information about the deceased; taking samples of bodily fluids; taking images such as through computed tomography (CT scans), X-rays, ultrasound and photograph; and analysing fingerprints.
Coroners Court of Victoria
While the Coroners Act 2008 (Vic) outlines the roles of pathologists, medical practitioners, and investigators, it does not explicitly mandate that specialist forensic pathologists perform all autopsies. However, it is implied that this will occur.
Autopsies must be conducted with consultation from VIFM or a designated pathologist, and the coroner may set specific conditions for these procedures.
Coronial findings are published on the Coroners Court of Victoria website and list the forensic pathologist who conducted the autopsy.
Impact
Outputs
In combination, the Coroners Act 2008 (Vic) and Victorian Institute of Forensic Medicine Act 2024 (Vic) provide the relevant legal frameworks for determining who can undertake autopsies to assist the work of coroners. While the Coroners Act 2008 (Vic) outlines the roles of pathologists and medical investigators, it does not explicitly require all autopsies to be performed by specialist forensic pathologists, as recommended in Recommendation 36. Under the Act it is possible for a registered medical practitioner under the general supervision of a pathologist to undertake an autopsy.
Outcomes
When a death is reported to the Coroner, the role of the VIFM’s forensic pathologists is to conduct medical examinations to determine the cause of death. These are performed or supervised by a specialist pathologist. The investigation of all deaths in custody, including Aboriginal passings, undergo mandatory review by a second specialist pathologist. All consultant pathologists at the VIFM are members of the Royal College of Pathologists of Australasia.
Coronial findings list the forensic pathologist who conducted the autopsy.