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Coronial law – preventing avoidable deaths and supporting bereaved families


Following advocacy by the Federation, CLCs, and other coronial system participants, the Victorian Parliament Law Reform Committee reviewed the Coroners Act 1985 in 2005-6. The Attorney General responded to the Committee’s final report by introducing the Coroners Bill 2008.

The Federation welcomed a range of improvements in the Bill. The Bill amended the provisions around self-incrimination to allow the release of information that might otherwise be unavailable to the coronial process and to affected families. The Bill also expressly included appeal rights - improving the rights of interested persons to appeal a coronial finding or decision not to hold an inquest.

However, the Bill ignored, or only partly implemented, key recommendations of the Committee’s Final Report. In particular, there was no requirement for relevant government agencies to respond to coronial recommendations directed towards them. Agencies could ignore or adopt them as they wanted without having to inform the court, the deceased’s family or the public, of the response.

Accordingly, the Federation pushed for changes to the Bill, providing a detailed submission to MPs outlining our concerns and suggested amendments. We also met with the Attorney-General’s advisers and the Shadow Attorney-General, and liaised with the Greens.

Outcomes of our work

The Federation’s initiatives assisted the debate in the Legislative Assembly and influenced the Bill’s passage in the Legislative Council, where important amendments were proposed and subsequently incorporated into the Coroners Act 2008.

The highlight of these amendments was the insertion of a requirement that if a Coroner makes recommendations to a particular Minister, statutory authority or entity, they must now respond within three months outlining actions that will be taken in response to the recommendations. The response must be published on the Internet and be provided to any interested person. This is a substantial gain for families and for the prevention focus of inquests. It makes Victoria only the second Australian state to mandate responses to all coronial recommendations.

The Australian Coronial Reform Project

There is still much more work to be done to establish a ‘joined up’ Australian coronial system that is sensitive to the bereaved, and that learns from past deaths in order to prevent future avoidable deaths. In 2010, the Federation convened a historic meeting of 30 coronial advocates, researchers, academics and policy/law reform workers across Australia to discuss national coronial reform and recommend changes to improve the system. As a result, the Australian Inquest Alliance was formed.

The Australian Inquest Alliance works for reform of coronial systems across Australia. Coroners in the different states and territories investigate avoidable deaths, determine the cause of death and recommend changes to bodies such as government departments, to prevent future deaths. Coroners can make potentially life-saving recommendations, yet the lack of a coordinated approach across Australia means that deaths with very similar causes and solutions can occur in one part of the country despite the fact that recommendations which might have saved those persons’ lives have previously been made in another jurisdiction. Nationwide research has found that it is also not unusual for recommendations to disappear into the ether and never be acted upon or even acknowledged by the bodies to which the recommendations are made.

In March 2013 Dr Norman Swan launched our Issues Paper, Saving Lives by Joining Up Justice, which outlines the need for coronial reform and includes 11 recommendations for change.

Contact Dr Chris Atmore for further information about our coronial law reform work.

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