Former deputy NSW coroner Hugh Dillon has called for a major shake-up of the state's coronial system, warning the current structure is a "recipe for mediocre service" and Local Court magistrates receive minimal training before presiding over inquests across the state.
Mr Dillon, who was deputy state coroner between 2008 and 2016, said in a damning letter to the NSW Auditor-General that "for a number of years" he had been "concerned our coronial system is failing the people of NSW" and urged the Audit Office to conduct a comprehensive review.
Former deputy state coroner Hugh Dillon says the state coronial system is "verging on dysfunction". Credit: Sahlan Hayes
Coronial work was done "on the cheap" in NSW, he said, and latest figures from the Productivity Commission showed the state's recurrent expenditure on coronial services was $6.8 million in 2016-17 compared with $13.2 million in Victoria and $10.7 million in Queensland. Victoria has nine full-time coronial positions and Queensland has eight, compared with five in NSW.
The system was now "verging on dysfunction" and the number of inquests in NSW declined from 150 in 2015 to 84 in 2017, Mr Dillon said. Reported deaths increased in the same period.
Unlike in Victoria, Queensland, South Australia and Western Australia, NSW does not have a stand-alone, specialist Coroners Court but uses a "hybrid" model, administered by the Local Court, where five full-time coroners are employed in Sydney and about 36 country and regional magistrates act as part-time coroners across the rest of the state.
Regional magistrates were carrying "almost half the coronial workload" in NSW and it was a "recipe for mediocre service", Mr Dillon said in his July 24 letter.
"Coronial work should be centralised in a specialist court, not farmed out to overworked, under-resourced, under-trained country magistrates," he said.
Coroners are selected from the ranks of the Local Court by the NSW Chief Magistrate. Mr Dillon said magistrates were encouraged to be generalists so they could be deployed across the state but the lack of specialisation in coronial work was "detrimental to the quality" of service in NSW, especially in regional areas. Little formal training was provided, "even to full-time coroners".
Shadow attorney-general Paul Lynch said Mr Dillon's comments "should be ringing alarm bells" and the issues he raised should be addressed in a statutory review of the Coroners Act, which has yet to be released by the Berejiklian government.
"Pretending the problem will go away – as the government does – just won’t work," he said. "And above all, the Coroners Court needs to be properly funded. At present it’s not."
The NSW Law Society has offered in-principle support for a specialist Coroners Court and president Doug Humphreys said "defects in the coronial system in NSW, along with a desperate lack of resources, are hindering it from reaching its potential to reduce the risk of preventable deaths and serious injury".
Mr Dillon, now an Adjunct Professor at the University of NSW Law School, said Local Court policy was to rotate magistrates every three to five years but "in my opinion, it takes about two years' full-time work to develop real competence as a coroner and five years to become expert".
There was "great untapped potential to help prevent death and injury" if the coronial system was designed and resourced properly, including by providing research support to help identify patterns and trends.
NSW Attorney-General Mark Speakman said he was "grateful to Mr Dillon for his continuing interest in the Coroners Court" and the Auditor-General Margaret Crawford had discretion as to whether she conducted a review. Her office did not respond to a request for comment.
The Department of Justice was finalising the statutory review of the Coroners Act, Mr Speakman said.
He said the government was “committed to ensuring the Coroners Court is adequately resourced, including by providing a new $91.5 million Forensic Medicine and Coroners Court complex at Lidcombe", with double the number of courts at Glebe and the capacity to "accommodate large and complex inquests".
Mr Speakman said the allocation of magistrates to the Coroners Court was a matter for the Chief Magistrate.
The state's new top coroner, Les Mabbutt, took on the new role in April after serving on the Local Court bench for 12 years, and is learning the ropes afresh. He replaced Michael Barnes, a seasoned operator who took on the job in 2014 after a decade as Queensland coroner.