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Coronial Law: The evolving institution of coroner

IAN FRECKELTON asks whether we are seeing the beginning of a process leading to mandatory responses to coronial findings.


Ian Freckelton is a Melbourne barrister

Far-reaching changes continue the process of transforming the role of the coroner from what it was in the early days of the Legal Service Bulletin. Only in New South Wales and Queensland do coroners retain the power to commit people for trial. In every other jurisdiction, the coroner’s role is confined to making findings in relation to deaths and fires, while in certain other jurisdictions coroners can also investigate and make findings about explosions (NSW, Tas), disasters (ACT, NT) and accidents (SA).

The identity of the trier of fact in coroners’ courts has also changed over the last quarter of a century. Most latterly under 1999 changes to the coronial legislation Victoria has joined all other jurisdictions in Australia, with the exception of New South Wales, in removing the fact-finding role in coroners’ courts from juries and entrusting it solely to the executive-appointed coroner. Historically, and practically, this is a most important shift toward ‘expert’ decision- making in coroners’ courts and removal of the role of the ordinary person from the process.

The Coroners (Amendment) Act 1999 (Vic) has also wrought other significant alterations to the way that the coroner goes about his or her fact-finding process in Victoria. Like the ACT the previous year, Victoria has now abolished, in respect of death inquests, the requirement for coroners to find the identity of any person who contributed to the cause of a person’s death. This occurred in the aftermath of the Victorian Court of Appeal decision in Keown v Khan (1998) 101 A Crim R 503 in which Callaway JA overtly doubted the utility of the provision mandating such a finding and questioned whether it imposed a requirement beyond the strictures of findings about how a person died and what constituted their cause of death. The Victorian legislation, however, continues to require that a coroner find, if possible, the identity of any person who contributed to the cause of a fire: Coroners Act 1986 (Vic), s.36(1)(c). In Tasmania, the requirement to find the identity of a person contributing to a cause of death remains: Coroners Act 1995 (Tas), s.28(1)(f).

A key issue for the efficacy of the coronial jurisdiction is what obligations that government departments, statutory authorities and other entities have to take notice of and implement coronial findings and recommendations. The issue goes to the heart of the coroner’s role as a modern-day inquisitor, as against an organ of state with coercive powers to enforce findings and ‘suggestions’. In Victoria, the overt powers of a coroner to ‘report’ to government beyond the Attorney-General were confirmed by 1999 amendment so that the coroner has jurisdiction to report to ‘any Minister or public statutory authority’: Coroners (Amendment) Act 1999 (Vic), s.11. However, what about where government, for instance, is obdurate to findings and recommendations by coroners? In most jurisdictions it can be so with impunity, the only sanction for the coroner being the adverse publicity likely to be generated by such intransigence, if the media draw attention it.

A tentative way to the future was perhaps shown by the 1993 Northern Territory coronial legislation. Where a Northern Territory coroner holds an inquest into the death of a person held in custody or who dies as a result of injuries caused or contributed to while in custody, the coroner is obliged to proffer recommendations with respect to the prevention of future deaths in similar circumstances: Coroners Act 1993 (NT), s.26(2). Not only this but the coroner is obliged to send such a report or recommendation ‘without delay’ to the Attorney-General who in turn is obliged to remit it to the appropriate Minister (s.27), the Attorney-General also having to present a copy of the report or recommendation to the Legislative Assembly within six sitting days of receipt. Neither the Minister, nor the Attorney-General, has to respond in any way to the report or recommendation, but the political pressure to do so is significant.

Similarly, under important, and potentially influential, changes introduced by s.75 of the Coroners Act 1997 (ACT) a coroner is obliged to report a record of his or her findings in relation to a death in custody to the Attorney-General, the custodial agency where the death occurred, the Minister responsible for the Agency, the Australian Institute of Criminology, and, if the deceased was an Aboriginal person or a Torres Strait Islander, to an appropriate Aboriginal legal service. The custodial agency to which the report is given has to respond within three months in writing to the relevant Minister: s.76(1). In its response, it is obliged to incorporate a statement of the action (if any) which has been, or is being, taken with respect to any of the findings contained in the report. By apparent oversight the mandated response does not relate to coronial recommendations.

What is revolutionary in respect of these changes is the introduction of an obligation on the part of people affected or the subject of coroners’ findings to respond in some way to what coroners have found to be the cause of death or other phenomena. Such a transformation of the coroner’s role has major repercussions in terms of rendering the coroner into an entity with the capacity to have a substantial impact on reducing the incidence of avoidable death and injury. It carries with it a significant change to the coroner’s role, though, as a solely arbitral, curial entity, other courts and judges’ rulings not being the subject of a legislated, mandated response on the part of those affected by them, unless orders are made in respect of parties.

Coroners’ hearings have assumed a dramatically more prominent community role over the past quarter of a century. A series of inquests into fatal shootings by police in Victoria lasted toward two years, the inquest into the Canberra Hospital implosion attracted nationwide publicity, the Thredbo inquest has attracted saturation media coverage, as did the Kew Cottages inquest in Victoria. At the time of writing, the Victorian inquests into a series of deaths in the privatised Port Phillip Prison at Laverton had also engaged substantial public interest.

The coronial inquest in Australia has taken a different direction from its English cousin, regularly constituting a major inquiry into death with a constructive focus into how the avoidable can be avoided. With the evolution, though, come new challenges. If inquests are to assume such prominence and to cost the state and others such substantial sums of money, they must be able to be justified in terms of the benefits they carry with them. This means they must not take longer or cost more than is absolutely necessary. Nor must they engender harm or suffering more than must accompany the achievement of their objectives. In addition, there must be sufficient political or structural sanctions against snubbing of the fruits of inquest findings and recommendations to render the process generally worthwhile. Ironically, while the Northern Territory and ACT initiatives and the greater connection of Victorian coroners’ findings with Ministers other than the Attorney-General may be the start of a process leading toward mandatory responses to coronial findings and recommendations, the main answer probably for the present lies with what has become an intrinsic aspect of coronial proceedings — the publicity given to them by the media. As in so many aspects of the law, what was apparent at the start of the Legal Sevice Bulletin era remains true a quarter of a century later. There are major limits to what courts’ decisions can accomplish if the parties have no wish to respond cooperatively. Ultimately, what engenders change most effectively is public opinion (often funnelled through the media) and the pressures that it brings to bear.


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