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New report urges national reform of badly fractured coronial system

Wednesday 6 March 2013 – for immediate release

A new report to be launched by the ABC’s Dr Norman Swan in Melbourne this morning urges comprehensive national reform of Australia’s flawed coronial system (event starts 10.30am Wednesday 6 March – see specific speaker times below).

The report makes 11 recommendations to ensure coronial recommendations result in meaningful, effective action to better prevent future avoidable deaths, and ensure families are properly supported to participate in investigations and inquests into the deaths of their loved ones.

“The Australian coronial system is badly fractured, with huge cracks through which grieving families are falling and social justice is being lost,” said Dr Chris Atmore, a lead author of the report and senior policy adviser with the Federation of Community Legal Centres, a member of the Australian Inquest Alliance, for which the report has been produced.

“A patchwork of State and Territory coronial processes too often results in a piecemeal approach that fails to live up to the fundamental obligation of the coronial system to help prevent deaths.

“Coroners can make potentially life-saving recommendations, only for them never to be responded to or implemented, with no follow-up and no public awareness of what has happened,” Dr Atmore said.

Drawing lessons from deaths through family violence, placement in care or custody, petrol sniffing, and the strangulation of children by cords on curtains and blinds, the report makes 11 key recommendations for national coronial reform.

Among these are legislative change, greater information-sharing, strengthened support for State and Territory coroners, and measures to ensure independence for coroners in investigating deaths and making recommendations that can be specifically targeted at government ministers, public statutory authorities and other entities.

Implementation of coronial recommendations would also be monitored by independent statutory authorities under the report’s proposals.

“This report poses deep questions about the capacity of our current coronial system to prevent deaths unless there is wide-ranging and urgent reform at Federal and State Government level.

“Adding further to its deep flaws, the current system takes a devastating toll on grieving families, who face unacceptable delays, and may even see further deaths occur in similar circumstances before recommendations are handed down. Too often they are left traumatised, mystified, frustrated and disempowered by the coronial process,” Dr Atmore said.

The report details a disturbing and shameful absence of legal representation and other supports to ensure the participation of families in determining the reasons why their loved ones died, and how deaths can be prevented in similar circumstances in the future.

“The hope of saving others from the grief they have experienced is one of the few consolations of the coronial process, yet families face lasting uncertainty about the impact of inquests. Only 20 per cent of families secure legal representation, with many failing to receive clear information about their inquest, or the essential supports that can help them get through,” Dr Atmore said.

Information about patterns of deaths, investigations and inquests is inappropriately restricted or expensive to access, the report says. Under its proposals, a National Inquest Clearing House (NICH) modelled on the UK’s INQUEST system would instead make information more widely available to family, advocacy organisations and members of the public.

“It’s time we had a Federally coordinated, cross-border approach to saving lives by joining up justice in our national coronial system,” Dr Atmore concluded.

Saving lives by joining up justice: Why Australia needs coronial reform and how to achieve it will be launched by Dr Norman Swan (11.50am) on Wednesday 6 March 2013 at the Lionel Murphy Centre, 360 Queen Street, Melbourne.

Other speakers include Victorian Legal Services Commissioner, Michael McGarvie (11.15am), and Cheryl Dyson and Wendy Phillips (11.30am), mother and sister of Lynette Phillips, findings of whose Victorian coronial inquest were handed down in December last year.

The launch will be preceded by a morning tea at 10.30am, and opening remarks and introductions by Claudia Fatone, Acting Executive Officer of the Federation of Community Legal Centres (11.00am).

Doors will be open from 10.00–10.40am (later access by buzzer). Media are encouraged to advise their attendance at the launch to Darren Lewin-Hill, Communications Manager, on 0488 773 535.

The report was generously funded by the Legal Services Board and is part of the Australian Coronial Reform Project. The Australian Inquest Alliance comprises 30 coronial advocates, researchers, academics and policy/law-reform workers from across Australia. Its first meeting was convened by the Federation of Community Legal Centres in 2010.

Media contacts

Dr Chris Atmore
Senior Policy Adviser
Federation of Community Legal Centres
03 9652 1500

Ray Watterson (telephone, from 2pm, 6 March)
Adjunct Professor of Law Latrobe University
0409 867 819

Darren Lewin-Hill
Communications Manager
Federation of Community Legal Centres
0488 773 535


Further information

Saving lives by joining up justice: Why Australia needs coronial reform and how to achieve it

Experiencing the coronial system – background information

Download this media release (PDF)

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