"Coroners, part of State and Territorial justice systems, are responsible for the investigation of unexpected deaths.  … Increasingly, coroners bring a preventive focus to their investigations and, accordingly have a vital role to play in the avoidance of Indigenous deaths. (Watterson, Brown and McKenzie, 2008: 4) 

The Royal Commission into Aboriginal Deaths in Custody (RCIADIC)  found in 1990 that the failure of coronial inquests to uncover the underlying causes of Aboriginal deaths in custody and to recommend remedial action had contributed to the nation’s massive failure to prevent many Indigenous deaths.  RCIADIC made a series of recommendations for improvement of the coronial process.  See recommendations 13 to 18 and 40 in particular.

In 2008 Ray Watterson, Penny Brown and John McKenzie, in Indigenous Law Centre publication the Australian Indigenous Law Review,reported on a national study of the law and practice relating to coronial recommendations and discovered that: “there is no uniform national system which reports whether or not coronial recommendations have been implemented by responsible government agencies.  Nor is there a uniform national scheme which ensures that coronial recommendations are properly considered by responsible government agencies.” (Watterson, Brown and McKenzie, 2008: 7)

In particular, they noted that: “there is no system in place which ensures that all coronial recommendations arising from Indigenous deaths in Australia are recorded in a form readily accessible to those who could draw from them in helping to prevent Indigenous death – for example Indigenous communities, Indigenous health workers, coroners, and government and private agencies with a responsibility for, or interest in, Indigenous wellbeing.” (Watterson, Brown and McKenzie, 2008: 7)

They called for Commonwealth, State and Territory governments to cooperate to introduce uniform national coronial legislation which provides a mandatory reporting and review scheme for all coronial recommendations.

The Northern Territory Coroners Act sets the benchmark as “the most comprehensive legislative scheme for government reporting and response to coronial recommendations.  It has one of the highest rates of government implementation of recommendation.” (Watterson, Brown and McKenzie, 2008: 20

South Australia, the Australian Capital Territory and Victoria all require mandatory responses to coronial recommendations.  New South Wales, Western Australia and Tasmania do not require any response to coronial recommendations.
Reference: Ray Watterson, Penny Brown and John McKenzie, ‘Coronial Reform and the Prevention of Indigenous Death’ (2008) 12 (Special Edition 2) Australian Indigenous Law Review 4.

This resource page provides links to legislation in each State and Territory, government policy and journal and media articles.

GENERAL INFORMATION

Leesha McKenny Push to ensure inquest edicts are followed, May 31, 2009

NT acts on coronial recommendations: Report findings

Coronial recommendations rarely implemented: study

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National Coroners Information System