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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
7
State Coroner responsible for inquiry into all deaths in custody
That the State Coroner or, in any State or Territory where a similar office does not exist, a Coroner specially designated for the purpose, be generally responsible for inquiry into all deaths in custody. (In all recommendations in this report the words 'State Coroner' should be taken to mean and include Coroner so specially designated.)
Aboriginal Justice Caucus Assessment
The intent of Recommendation 7 was to ensure that the State Coroner, or a specially designated coroner be responsible for inquiry into all deaths in custody.
The Aboriginal Justice Caucus (AJC) determined that actions taken partially align with the intent of this recommendation. The State Coroner issued Practice Direction 6 of 2020 to improve coronial processes, support all coroners to carry out inquiries into Aboriginal deaths in custody, and strengthen the Court’s response to RCIADIC recommendations regarding coronial processes.
Immediate actions following the death of an Aboriginal person in custody include that, where practicable, the State Coroner and/or delegate (such as the duty coroner) will always attend the scene of the death in custody of an Aboriginal person, in consultation with the Coroners Aboriginal Engagement Unit.
The AJC found some evidence of outcome. The Coroners Act 2008 (Vic) outlines that the State Coroner is responsible for ‘ensuring the effective, orderly and expeditious discharge of the business’ and is able to assign duties to a coroner. Examination of the last seven inquests into Aboriginal deaths in custody in Victoria revealed that different coroners presided over each of them including in one instance, the Deputy State Coroner.
Recommendation 7 was considered less relevant today as issues identified by the RCIADIC in relation to the delegation of coronial duties to a Justice of the Peace or others not specifically trained for inquiry into deaths, have not existed in Victoria since the State Coroner’s Office was established in 1985.
The AJC assessed Recommendation 7 as a low priority for further work but noted that requiring the State Coroner or designated coroners with appropriate expertise to investigate all Aboriginal deaths in custody, could potentially improve the quality and consistency of these investigations.
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
Improve the quality and consistency of investigations into Aboriginal deaths in custody
Require the State Coroner or designated coroners with appropriate expertise to investigate all Aboriginal deaths in custody.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) highlighted issues with coronial investigations across states and territories. These included the delegation of coroner duties to less experienced officers, and instances where coroners depended heavily on police for guidance on coronial matters, creating public uncertainty around investigative outcomes. To address these issues, the RCIADIC advocated for all deaths in custody to be investigated by a State Coroner or specially appointed coroner to ensure greater consistency in coronial inquiries, and a more thorough, independent and informed approach to enhance the effectiveness of coronial inquiries.
At the time this recommendation was made, the Victorian coronial system established under the Coroner’s Act 1985 was ‘widely regarded as the most innovative and efficient within Australia’ and worthy of being examined as a model for other states and territories. Coroners had jurisdiction to investigate reportable deaths, and the State Coroner had a statutory power to give other coroners directions about the preliminary investigation into a death and the manner of conducting it. While the State Coroner did not have an equivalent power to direct other coroners in respect of their conduct of inquests, the RCIADIC concluded that the ‘State Coroner is ultimately responsible for the investigation of all deaths in Victoria.’
Actions Taken Since Last Review
Coroners Court of Victoria
In 2020, the State Coroner issued Practice Direction 6 of 2020 outlining new protocols for the conduct of coronial investigations into Aboriginal deaths in custody. This directive aims to enhance coronial practices and strengthen the Court’s response to recommendations made by the RCIADIC regarding coronial processes.
Coronial Investigation
The coronial investigation process involves coordination between various organisations to ensure prompt and thorough investigations into specific types of deaths. Deaths investigated by a coroner include unexpected, unnatural, or violent deaths, cases where the identity or cause of death is unknown, and deaths occurring while a person is in care or custody. Specifically, the Coroners Act 2008 (Vic) states that a coroner must investigate any death that occurs in custody or as a result of a police operation.
Impact
Outputs
Under the Coroners Act 2008 (Vic), a coroner must investigate reportable deaths including all deaths in custody. While the Act does not specify that the State Coroner is responsible for inquiries into all deaths in custody, it does note their authority to assign duties to coroners.
Outcomes
The Coroners Act 2008 (Vic) outlines that the State Coroner is responsible for ‘ensuring the effective, orderly and expeditious discharge of the business’ of the Coroners Court and can assign duties to a coroner.
Examination of the seven most recent inquests into Aboriginal deaths in custody in Victoria revealed that different coroners presided over each of them. In one instance, it was the Deputy State Coroner, while in others, it was another coroner or delegate of the State Coroner.
Community Views
Research into Bereaved Family Members’ Experiences of the Coronial Porcess
The Centre for Innovative Justice consulted bereaved families about their experiences of the coronial process. The differences between coroners and their respective approaches to conducting an inquest, were highlighted in this context:
One family member said that as a member of the Aboriginal community, she had some knowledge of previous coronial investigations into the deaths of Aboriginal people and as a consequence had low expectations that the process would be culturally safe for her family. She was also aware that families could have different experiences because of the varying attitudes and approaches of Coroners.