A crippling backlog of hundreds of coronial cases, including deaths in police custody, is forcing grieving families of the deceased to wait years for closure in the form of an inquest, as the Coroners Court battles with mounting workloads and sparse resourcing.
Legal experts estimate there is now a backlog of between 130 and 140 mandatory inquests into deaths in custody, or during police operations, in NSW, with some dating back several years.
Rebekah Keukenmeester’s 10-year-old daughter Bridgette was murdered in 2020. She was granted an inquest after directly appealing to the state coroner.Credit: Advocacy Australia
At the same time, families are increasingly resorting to petitioning the state coroner to take on high-profile cases, in part because insufficient resources coupled with the case backlog has led to fewer discretionary inquests being scheduled.
“We were originally told an inquest wouldn’t be held, that there didn’t need to be one, but we were lucky because we had the help of Advocacy Australia – they helped me to write a letter to the coroner, and the coroner said yes,” said Rebekah Keukenmeester, whose daughter Bridgette “Biddy” Porter was murdered in 2020.
“In saying that, we’ve not been told when it will actually be, just ‘watch this space, and we’ll get back to you’.”
At the heart of the problem is a growing caseload, coupled with a long-term funding shortfall. While the number of cases reviewed by the coroner has steadily increased in NSW – from 5340 in 2013 to 7338 in 2023 – the number of inquests has steadily fallen, from 142 to 103 over the same period.
NSW’s relatively parlous resourcing of the court may explain the problem. In Victoria, there are 14 fulltime coroners. Queensland, with a much smaller caseload, has 10. In NSW, there are only six, while local magistrates are sometimes used in regional areas.
Unlike most other states, NSW does not have a stand-alone Coroners Court but uses a “hybrid” model administered by the Local Court. Data from the Productivity Commission shows it is also relatively underfunded. Victoria spent about $27 million on coroners courts in 2022-23, compared with $10 million in NSW, the data shows.
Despite acknowledging before the election that the state coroner “lacks sufficient resources”, the government has so far failed to move on significant reform. Last year a statutory review of the NSW Coroner’s Act recommended an overhaul of the court, and the government says it is reviewing its findings.
While Attorney-General Michael Daley conceded in a recent budget estimates hearing that the court faced “head count” issues, he said major reform to make the court a specialist jurisdiction would be “very expensive”. He recently funded an additional two “behind the scenes” solicitors to help with the caseload, and the government has injected additional funding to carry out an inquest into the Bondi Junction attack.
The backlog has prompted concerns that many preventable deaths may be going unexamined, with the Coroners Court unable to shift its focus to cases that could help prevent people from dying.
“The coroners are up to their ears in mandatory cases, and they are trying to reduce the backlog, but they simply do not have sufficient resources,” former NSW deputy state coroner and University of NSW adjunct professor Hugh Dillon said.
“That means there is less and less room for discretionary inquests, which is important because those are more likely to result in preventive recommendations which can stop deaths occurring. The system is not working as it should be.”
It took a year after Bridgette Porter’s death in 2020 – a shockingly violent case in which her murderer was found guilty but not criminally responsible in 2021 – before the coroner wrote to the family to say an inquest would not be held.
That changed in 2024, when Keukenmeester wrote to the coroner requesting an inquest to probe into whether signs were missed in the lead-up to her daughter’s murder – including the mental health of the perpetrator – which could have prevented it.
“We felt that if signs had been acted on earlier, then Biddy’s death could have been prevented,” she said.
“That’s what we’d like to have come out, as well as some transparency around the decision-making of certain people.”
The coroner’s workload also means longer wait times for families in cases where an inquest is granted.
Of the 75 relevant coronial findings in 2024, 73 per cent took more than three years from the date of death or suspected death to completion, Dillon said.
Some inquiries and reviews have recommended an overhaul of the Coroners Court. In 2022, a parliamentary select committee, led by former Labor MP Adam Searle, recommended the court be reformed into an “autonomous and specialist” unit separate from the Local Court, and receive an injection of funding to address delays and backlogs.
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