‘Fundamental change’: Blueprint for Coroners Court shakeup revealed

A new, standalone Coroners Court in NSW would replace the outdated system in which regional magistrates act as part-time coroners in a long-awaited modernisation recommended by the state’s justice department.

A review of the Coroners Court, released last week, recommended a series of changes including making death prevention an explicit focus of the court’s work and, where possible, reducing formality and technicality in proceedings.

The Forensic Medicine and Coroners Court in Lidcombe.Credit: Rhett Wyman

Creating a standalone court within the Local Court framework is the centrepiece reform recommended in the review, conducted by the Department of Communities and Justice for Attorney-General Michael Daley. But the recommendation is made subject to a caveat that resources are available.

Under the existing hybrid model, NSW does not have a specialist Coroners Court. It exists within the Local Court structure and employs fewer than 10 full-time coroners in Sydney, including State Coroner Teresa O’Sullivan, to handle metropolitan cases. Regional magistrates act as part-time coroners elsewhere in the state.

Former deputy state coroner Hugh Dillon, who has long called for root-and-branch reform of the coronial system, welcomed the report and said “creating a standalone court is an absolutely necessary reform”.

“The recognition that coronial work is specialist work, it’s not just a sideline for busy magistrates … is a fundamental change, and it’s very much to be welcomed,” Dillon said.

He said that “overall [the report is] … a remarkable advance on where we were two years ago” but its implementation “all depends on cabinet and Treasury, in particular”.

Former deputy state coroner Hugh Dillon has long called for root-and-branch reform of the coronial system.Credit: Sahlan Hayes

“It’s a very big step towards reform, and … the government really should not go backwards,” Dillon said.

“The government should see this, a reformed Coroners Court, as an investment. Saving lives has an economic benefit, not just a social benefit. I think it’s important Treasury recognises that.”

The review of the Coroners Act, which languished under the former Coalition government, started in 2014.

The report recommends an amendment to the court’s objectives to state explicitly that its work “should contribute to the reduction in the number of preventable deaths”.

It also calls for the Coroners Act to be amended to include a series of factors coroners should consider when exercising their functions. Among these is the distress that deaths caused to families and communities and the importance of keeping family members informed during investigations.

Dillon said recognition of bereaved families and making them central to the process, and trying to prevent future deaths, were “both excellent advances”.

Prevention was “really important to families”, he said, pointing to the recent high-profile inquest into the death of Manly Sea Eagles player Keith Titmuss, who likely died of exertional heatstroke.

The report also recommends further amendments to allow “coronial proceedings to be conducted with as little formality and technicality as the interests of justice permit, and with as little emphasis on an adversarial approach as possible”.

The state coroner was “very keen to make the court’s processes more restorative, more therapeutic, and less adversarial”, Dillon said. “Taking it outside of what is the busiest criminal court in Australia”, the NSW Local Court, would have “important flow-on effects” in helping to change the culture.

Dillon said the report, regrettably, contained “no mention of appointment of First Nations coroners or commissioners” to sit on inquiries relating to the death of a First Nations person.

Bar Association president Dr Ruth Higgins, SC, noted NSW was “the only jurisdiction in Australia which relies on regional magistrates and court registrars to undertake coronial responsibilities”. She said the state government “should take this opportunity to modernise and enhance the coronial jurisdiction” by allocating funds in the 2024-25 budget for a standalone court.

A standalone court with adequate resources would “deliver more expertise, better outcomes, and additional support for grieving families”, Higgins said. It would have “a greater capacity to ensure that families ... understand why a death has occurred, and will increase the prospect of avoiding future deaths”.

“Coronial reform should recognise the unique status and needs of First Nations people, who are over-represented in custody,” Higgins said.

Daley said the government would consider the report’s recommendations.

Start the day with a summary of the day’s most important and interesting stories, analysis and insights. Sign up for our Morning Edition newsletter.