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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
41
National monitoring of deaths in custody
That statistics and other information on Aboriginal and non-Aboriginal deaths in prison, police custody and juvenile detention centres, and related matters, be monitored nationally on an ongoing basis. I suggest that responsibility for this be established within the Australian Institute of Criminology and that all custodial agencies co-operate with the Institute to enable it to carry out the responsibility. The responsibility should include at least the following functions:
a) Maintain a statistical data base relating to deaths in custody of Aboriginal and non-Aboriginal persons (distinguishing Aboriginal people from Torres Strait Islanders).
b) Report annually to the Commonwealth Parliament; and
c) Negotiate with all custodial agencies with a view to formulating a nationally agreed standard form of statistical input and a standard definition of deaths in custody. Such definition should include at least the following categories:
i. the death wherever occurring of a person who is in prison custody or police custody or detention as a juvenile;
ii. the death wherever occurring of a person whose death is caused or contributed to by traumatic injuries sustained or by lack of proper care whilst in such custody or detention;
iii. the death wherever occurring of a person who dies or is fatally injured in the process of police or prison officers attempting to detain that person; and
iv. the death wherever occurring of a person who dies or is fatally injured in the process of that person escaping or attempting to escape from prison custody or police custody or juvenile detention.
For myself as a family member I haven't been asked to contribute to this and I know as the executive officer of the Dhadjowa Foundation, which is a national grassroots organisation that supports Aboriginal deaths in custody families, we also have not been consulted on this…
As an individual tool, I don't think it's going to achieve a lot on its own. If this was to come alongside preventative and accountability measures, I think that could make a difference
It's long overdue but for me I do actually find this quite confusing and problematic in that this is the first I've heard of it.
It's the things that are causing these deaths that need to actually be addressed
Aboriginal Justice Caucus Assessment
The intent of Recommendation 41 was for the Australian Institute of Criminology (AIC) to maintain a database based on a standard definition of deaths in custody and standard form of statistical input, with annual reports to the Commonwealth Parliament.
The Aboriginal Justice Caucus (AJC) determined that several actions had been taken in line with the intent of this recommendation, but some actions, like reporting annually to Parliament had not continued over time. The AJC continue to be concerned about the definition of a death in custody and fatalities that may be missed based on the current definition. This was discussed further in relation to Recommendation 6.
The AJC noted the importance of states and territories maintaining consistent records of Aboriginal deaths in custody to support identification of systemic issues and failures that contribute to such passings. The AJC found that Recommendation 41 remains relevant, with the data produced crucial to supporting Aboriginal self-determination and advocacy for reforms to prevent further deaths.
The AJC found a clear link between the establishment of the National Deaths in Custody Program by the AIC, the National Coronial Information System and the changes intended by Recommendation 41. However, they considered that greater Aboriginal involvement in their oversight, would be beneficial.
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
Increase Aboriginal involvement in the oversight of coronial databases
Increase Aboriginal community representation on the National Deaths in Custody Program Steering Group and oversight of the National Coronial Information System.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) found that national data collection and reporting were critically important in identifying systemic failures in custodial practices that could be addressed to prevent further deaths in similar circumstances. The Commission emphasised the importance of, and urgent need to collect and maintain accurate information about deaths in custody that distinguished Aboriginal people from Torres Strait Islanders and non-Aboriginal people. Publicly available, accurate information was essential for transparency and accountability of custodial agencies and governments.
Actions Taken Since Last Review
National Coronial Information System
The NCIS, established in 2000 in response to recommendations from the RCIADIC, is a secure database of information on over 450,000 cases investigated by coroners in Australia and New Zealand. Data includes demographic information on the deceased, contextual details on the nature of the fatality, and searchable case reports. While jurisdictional differences affect the information available in the NCIS, as far as possible the data is nationally standardised.
Funding for the NCIS is provided by all Australian states and territories, New Zealand and select Commonwealth Government agencies including the AIC. Administration of the NCIS is carried out by a team in the Victorian Department of Justice and Community Safety.
Coroners have access to the NCIS to assist investigations, and appropriate access is available on application for research or monitoring projects. NCIS data also supports AIC monitoring.
National Deaths in Custody Program – Real-time reporting
The NDCIP database is maintained by the AIC as a direct outcome of the RCIADIC. The AIC produce regular reports to track trends in relation to Aboriginal deaths in custody and make comparisons between jurisdictions.
In June 2023, the AIC introduced real-time reporting of deaths in custody. Data published on the real-time dashboard are drawn from NDICP data collection forms provided by state and territory police services, correctional departments and youth justice agencies. This data includes deaths that fall clearly within the scope of the NDICP and accord with the definition outlined in part c) of this recommendation.
When real-time reporting was introduced the Attorney-General noted it was part of a broader $99 million Commonwealth Government investment in Aboriginal justice initiatives:
We want to end deaths in custody. We want to grapple with systemic problems that are there in the system . . .This is only part of the solution but it's an important part.
Data provided by state and territory police services, correctional departments and youth justice agencies are cross-referenced with coronial records sourced from the NCIS.
The AIC confirms deaths in custody data with data providers at the end of each quarter, prior to preparation of the Deaths in custody in Australia quarterly dashboard, and again prior to preparation of the Deaths in custody in Australia annual report. Following the quarterly and annual verification processes, data may be revised on the real-time dashboard.
Impact
Outputs
National Coronial Information System
The NCIS core data set was agreed upon by all participating jurisdictions upon its establishment in 2000. The NCIS Unit monitors the provision of information from coroners courts against the core data set.
Aboriginal and/or Torres Strait Islander identification
The NCIS contains two fields which indicate whether an individual identified as an Aboriginal or Torres Strait Islander person. Coronial information is supplemented with Indigenous status information from each state/territory Births, Deaths and Marriages registry. The latter data originates from the death registration process and/or medical certificate cause of death.
Collecting two data sources for Aboriginal and Torres Strait Islander identification in the NCIS recognises the importance of this information for death and injury prevention work. It acknowledges the difficulty of collecting comprehensive and accurate data about Aboriginal and Torres Strait Islander identification in administrative data sets. Two data sources provide greater coverage and a reduced reliance on one administrative process to capture this characteristic. It supplements Australian coronial data for these variables which are not always consistently collected.
Outcomes
National Deaths in Custody Program
The NDICP has monitored the extent and nature of deaths occurring in prison, police custody and youth detention since 1980. The NDICP was established at the AIC in 1992 in response to this recommendation.
The NDICP provides real-time and quarterly data dashboards on deaths in custody in Australia and annual reports of the same name. On 1 July 2025, the real-time dashboard indicated there had been 598 Aboriginal deaths in custody since the RCIADIC.
Community Views
Hannah McGlade
We've been calling for real-time reporting because otherwise people really aren't aware there's been another death in custody and the circumstances of that death.
Apryl Day
For myself as a family member I haven't been asked to contribute to this and I know as the executive officer of the Dhadjowa Foundation, which is a national grassroots organisation that supports Aboriginal deaths in custody families, we also have not been consulted on this…
As an individual tool, I don't think it's going to achieve a lot on its own. If this was to come alongside preventative and accountability measures, I think that could make a difference
It's long overdue but for me I do actually find this quite confusing and problematic in that this is the first I've heard of it.
It's the things that are causing these deaths that need to actually be addressed