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The Coroner’s Court can save lives – not just review deaths


Tuesday 3 May 2022, 2:00 pm


The Aboriginal Legal Service has welcomed the findings of a NSW Parliament inquiry into the Coroner’s Court, saying the Court could help prevent future Aboriginal deaths in custody.

A parliamentary committee found the current system is overloaded, underfunded and lacks power to create change, making 35 recommendations to improve how the state conducts coronial inquests.

“By its nature, the Coroner’s Court only deals with matters after a person has died. Yet it has huge, untapped potential to save lives, because of its unique position to consider the systemic issues that have caused deaths and make recommendations to stop these lethal patterns in their tracks,” said Karly Warner, CEO of the Aboriginal Legal Service (NSW/ACT) Limited (ALS).

The parliamentary committee agreed that the Court should examine systemic issues, recommending the creation of a specialist preventive death review unit. The committee also called for coroners to have greater “follow-up power” to compel action when they make recommendations arising from an inquest.

“It’s incredibly frustrating and sad for families to sit through days of hearings into their loved one’s death, only for nothing to change. Many families only go through this process because they hope to save the life of the next person,” Ms Warner said.

“The government, police and prisons need to be accountable to grieving families and provide the Coroner’s Court with follow-up power to ensure we save the next life. Recommendations need to become actions, not just words on paper.”

When investigating the deaths of individual Aboriginal people in custody, the committee also wants coroners to consider whether full implementation of recommendations from the Royal Commission into Aboriginal Deaths in Custody could have reduced the risk of death.

“The Royal Commission into Aboriginal Deaths in Custody ended over 31 years ago, but so many of the solutions it found have been ignored by governments. More than 500 Aboriginal people have died in custody in the meantime. Our communities are literally sick from saying goodbye to loved ones. How many more reports will it take?” Ms Warner said.

The committee made several other recommendations that could promote accountability to Aboriginal communities, including keeping families informed of coronial proceedings, providing counselling and financial assistance, and increasing the quota of Aboriginal staff at the Coroner’s Court. Importantly, it also recommended additional funding to the ALS, so that the service can provide legal and practical support to more Aboriginal families experiencing coronial inquests.

“We especially welcome recommendation 18 that the Coroner’s Court appropriately balances the needs and interests of families with other considerations. The Coroner’s Court is always going to be a distressing place, but it should be somewhere that provides closure rather than compounding upon trauma. It should be a place where families feel respected and the humanity of the deceased is recognised,” Ms Warner said. 

The ALS is now calling on the NSW Government to respond to the report and, in particular, accept the parliamentary committee’s recommendations focusing on adequate funding, prevention of further deaths, follow-up powers, and accountability to Aboriginal families and communities.




Media contact: Alyssa Robinson [email protected] 0427 346 017


The Select Committee on the coronial jurisdiction in New South Wales’ report can be found here: https://www.parliament.nsw.gov.au/lcdocs/inquiries/2809/Report%20No.%201%20-%20Select%20Committee%20on%20the%20coronial%20jurisdiction%20in%20New%20South%20Wales.pdf

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