Three of the state’s top past and present coroners are backing calls from the legal fraternity for a major overhaul of how deaths in NSW are investigated, through the creation of a stand-alone Coroners Court cut off from the Local Court.
Former state coroner Mary Jerram AM has joined her successor Michael Barnes and her former deputy Hugh Dillon in calling for the revamp. The proposal is being examined by a state parliamentary inquiry and has the backing of the Law Society of NSW and victims’ groups.
Former coroner Mary Jerram.Credit: Sahlan Hayes
It comes as families and representatives of high-profile victims have told the inquiry more resourcing is needed to address a system beset by delays and of their concern regarding a lack of follow through on coronial recommendations.
Professor Hugh Dillon, who was deputy state coroner between 2008 and 2016, has been one of the most vocal critics of the system.
He said the inquiry was a “once-in-a-generation” opportunity for change.
Each year about 6500 deaths are reported to the Coroners Court, which has responsibility for ensuring sudden, unexpected or unexplained deaths are properly investigated. The structure has the court falling within the Local Court. It is serviced by specialist coroners in Sydney and Local Court magistrates in country and regional areas.
“NSW is the last major jurisdiction in Australia to rely on such a structure,” Professor Dillon said.
Professor Dillon stressed regional magistrates were hardworking experts in criminal law.
However, they struggle with the additional demands of coronial cases and were not trained in identifying complex system failures which lead to preventable deaths, he said.
“They hold few inquests and rarely make recommendations,” he said.
Professor Dillon said the specialists in Sydney were forced to take on much of the regional workload as well as metropolitan cases, deaths in custody and police operation cases.
“The specialist coroners are over-stretched and under-resourced … as a consequence, delay, and therefore distress for families, is endemic in the system,” he said.
Ms Jerram served as state coroner from 2007 to 2013. She told the inquiry she “totally supported” Professor Dillon’s comments.
“We discussed the lack of resources, independence and needs of the Coronial Court many times and have continued to do so since I left the jurisdiction,” she said.
State Coroner Barnes previously has warned that “inconsistent and inappropriate decisions” were being made by regional magistrates which could be resolved by creating a specialist court.
The calls for a stand-alone court were echoed in submissions to the inquiry by the NSW Bar Association, the Law Society of NSW and the Australian Lawyers Alliance.
The alliance’s NSW president Joshua Dale was one of multiple parties who raised concerns about follow through on recommendations. He argued government agencies should respond in writing with actions to be taken within six months of receiving recommendations.
Professor Dillon said government agencies “frequently miss set deadlines and sometimes do not appear to respond at all.”
The Aboriginal Legal Service called for the coroner to be given expanded powers to follow up and ensure compliance with recommendations.
Justice Action represented the family at an inquest into the death of David Dungay junior, who died in Long Bay Jail in 2015 after guards rushed to stop him eating biscuits.
Justice told the inquiry there was a “clear lack of follow through” on reporting systems failures and making coronial findings publicly accessible.
“For instance, the recommendations made following the David Dungay inquest were restricted to Long Bay Prison Hospital rather than offered to prisons more broadly,” its submission said.
Another common complaint was the length of time it took coronial matters to reach a conclusion. The Australian Lawyers Alliance noted the inquest process for Thomas Redman, an 18-year-old who died near Gloucester, took five years.
Leesa Topic’s daughter Courtney was shot dead by police during a mental health crisis outside Hungry Jack’s at Hoxton Park in 2015.
Courtney Topic’s parents Leesa and Ron speak to the media outside the NSW Coroners Court after the findings into their daughter’s death were handed down. Credit: Jessica Hromas
The inquest was held three years later and the hearings were adjourned several times throughout.
“The disjointedness of the whole process, from start to finish definitely added to our trauma,” Ms Topic told the inquiry.
In its submission, the NSW government said it had established a task force in 2019 to reduce delay in coronial proceedings.
An additional magistrate was assigned exclusively to deal with coronial matters in the 2021-22 budget.
The government argued there were several advantages to having the Coroners Court form part of the local court, including increased flexibility in managing judicial resources, increased access to judicial resources for coroners and reduced risk of vicarious trauma.
“Magistrates may be rotated to avoid excessive exposure to traumatic coronial material,” the submission said.
The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.