SubmissiontotheNationalHumanRightsActionPlan
BaselineStudy Consultation
AustralianInquestAlliance
September2011
Inquiriesto:
DrChrisAtmore
PolicyOfficerFederationof CommunityLegalCentres (Vic)Inc
0396521506
Orifbefore19September
RayWattersonAdjunct ProfessorofLawLa TrobeUniversity
0249294500
Introduction
TheAustralianInquestAlliance(theAlliance)consistsofagrowingnumberof organisationsandindividualsacrossStateandTerritoryborders,includingcommunity legal centres,AboriginalandTorresStraitIslanderLegalServices(ATSILS), advocatesfor imprisonedwomenandmen,andacademicresearchers.
TheAlliancehasasignificantdepthofadvocacy,researchandsocialpolicyexperience and expertiseovermanyyears.Thisknowledgeencompassescoronialinvestigations,inquests,humanrightsandbroadercoronialframeworksacrossjurisdictionalboundaries.
TheAllianceseekssystemicchangeinordertoeliminateandreducepreventabledeaths. WebelievethatthisrequireseachStateandTerritorytoeffectivelyaddressthe structural issuesunderpinningpreventabledeaths.
WewelcometheopportunitytocommentonAustralia’sNationalHumanRightsActionPlan BaselineStudy.1 Thefocusofoursubmissionis inclusionofissuesforreform ofcoronial systemsacrossAustraliaintheBaselineStudyandsubsequentNationalHumanRightsAction Plan,sothatsocialjusticemaybeeffectivelypursuedfor thosewhohavediedin circumstanceswherethedeathmayhavebeenprevented.
Overviewofthesubmission
TheBaselineStudyConsultationDraft(BaselineStudy)aimstofacilitateidentificationof priorityareasofactionforinclusionintheNationalHumanRightsActionPlan,inorderfor humanrightstobefurtherrespected,protectedandfulfilled.It seekstodothisbyprovidinga summaryofhowhumanrightsarecurrentlyprotected inAustralia.
Withrespecttopreventabledeaths,theBaselineStudydoesnotdrawontherelevant human rightsjurisprudenceandmechanismsconcerningAustralia’sobligations,anddoesnotadequatelyoutlinetherelevantevidence.2 Accordingly,theBaseline Studyfailstosufficiently documentthecurrentstateofaffairsinwhichtheright tolifeisnotbeingsufficiently respected,protectedorfulfilledinAustralia.
WefirstidentifythegapsintheBaselineStudyconcerningprotectionandpromotionof the righttolife.WeexplainwhytheAustralianGovernmentisfurtherobligatedtoaddress violationsoftherighttolife,byfleshingoutthehumanrightsobligations
1 Theprincipal author of this submission is the Federation of Community Legal Centres Victoria. The submission is endorsed by:Ray Watterson, Adjunct Professor of Law, La Trobe University; Sisters
Inside;Aboriginal & Torres Strait Islander Legal Service (Qld) Ltd; Victorian Aboriginal Legal Service
Co-operativeLimited; Deaths in Custody Watch CommitteeWA.
2 Thereis some brief reference to different kinds of deaths such as those resulting from TASERs (12-
13)and youth suicide (40-41), but no links are made to Australia’s obligations concerning the right to life. Other than briefly noting UPR Recommendations concerning Aboriginal and Torres Strait Islander deaths in custody (27), the Baseline Studydoes not discuss any implications for the coronial system.
2
documentedintheBaselineStudy.WethensuggestadditionstotheBaselineStudyin the formofevidenceofhumanrightsviolationsconcerningtherighttolife.
WeunderstandthattheAustralianGovernmentiscommittedtofurthercommunity consultation concerningthecontentoftheNationalHumanRightsActionPlan.Inthefinalpart ofoursubmission,wemakesomepreliminarycommentsconcerningnecessary measuresand specificactionstoimproveAustralia’shumanrightssituationconcerningtherighttolife, withthefocusonAustraliancoronialsystems.
Protectionandpromotionoftherighttolife
Relevant humanrights
Therighttolife3 isafundamentalhumanrightthatisnowunderstoodtoincludethe requirement thatStatesmustprotectindividualsagainsttheactionsofnotonlyStatebut also privateactors,4 andtoencompassfreedomfromviolenceagainstwomenthat islife threatening.5 Inthislastrespectweendorsethesubmissionof theFederationofCommunity LegalCentresVictoriaconcerningtheneedfor‘joinedup’domestic/familyviolencedeath reviews.
Therighttolifeandtherighttoaneffectiveremedyforviolationarebreachedwherethe AustralianGovernmentdoesnottakeadequatestepsormeasurestointerveneor protect lives.6
Therighttolifealsorequiresthatfamiliesofthedeceasedbefullyinformedandempowered toparticipateinthecoronialprocess,withgenuineaccesstolegalrepresentationininquests.7 Therighttolifefurtherrequiresthatthecoronialprocesstake placeinan accountableandgenuinelypreventativeframework.8
Otherhumanrightsrelevanttopreventabledeathsincludetherighttofreedomfromtorture, inhumanordegradingtreatment;9 therighttofreedomfromdiscrimination;10
3 Article6, International Covenant on Civil and Political Rights 1966, GA res. 2200A (XXI),16 December
1966,999 UNTS 171 (entered into force 23 March 1976).
4 Seeeg Alice Edwards, Violence Against Women Under International Human Rights Law(2011) 264.
5 UNHuman Rights Committee, Concluding Observations on Peru, UN Doc. A/52/40 (Vol. I) (1997); UN Human Rights Committee, Concluding Observations on Colombia, UN Doc. A/52/40 (Vol I) (1997); UN
HumanRights Committee, General Comment No. 28: Equality of Rights Between Men and Women.
6 Kontrovav Slovakia [2007] ECHR 419 (31 May 2007).
7 Ron the Application of Amin v Secretary of State for the Home Department [2004] 1 AC 653, 25, 43,
44,50, 51; R on the Application of D v Secretary of State for the Home Department[2006] All ER 946, para 9(iii); Jordan v United Kingdom(2001) 37 EHRR 54, para 105-9; Leslie Thomas, Adam Straw and
DannyFriedman, Inquests: A Practitioner’s Guide (2nd Ed, 2008), 360-79.
8 RoyalCommission into Aboriginal Deaths in Custody(RCIADIC) National Report Vol 1 (1991), [4.7.4]; Graeme Johnstone, ‘An Avenue for Death and Injury Prevention’ in Hugh Selby (ed),The Aftermath of Death (1992) 140; James Reason, ‘Human Error: Models and Management’ (2000) 320British Medical
Journal768; David Ranson, ‘The Role of thePathologist’ in Hugh Selby (ed),The Aftermath of Death
(1992)80, 120-21; State Coroner of Western Australia, Findings and Recommendations of the Inquest into the Death of Mr Ward, 12 June 2009.
9 Article 2, Convention Against Torture and Other Forms ofCruel, Inhuman or Degrading Treatment or
Punishment,opened for signature 4 February 1985, 1465 UNTS 85 (entered into force 26 June 1987); Article 7, International Covenant on Civil and Political Rights, opened for signature 16 December 1966,
999UNTS 171 (entered into force 23 March 1976).
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therighttoequalitybeforethelaw;11therighttoprotectionof family;12therightto health;13andtherighttoaneffectiveremedyforrightsviolations.14
Need forafederalHumanRightsAct
WhileweunderstandthattheAustralianGovernmentwillnotconsidertheissueof comprehensivelegislativehumanrightsprotectionuntilatleast2014,wereiterateour strongsupportforafederalHumanRightsAct.Suchlegislationwasalsooverwhelmingly calledforinpublicresponsestotheNationalHumanRightsConsultation.TheUnited NationsHumanRightsCouncil,throughtheUniversalPeriodic Review(UPR)process (Recommendation86.22),hasrecommendedthatAustraliaadoptsuchlegislation.
Need forgreaterpowersofAustralianHumanRightsCommission
TheAustralianHumanRightsCommissionhasalimitedrolebecauseit doesnothave authoritytomakeenforceabledeterminationsortorequiretheAustralianGovernment to implementorrespondtoitsrecommendations.UnitedNationsCommittees have recommendedthattheCommission’smandatebestrengthenedand thatits recommendationsbegivenadequatefollow-up.15TheUPR
recommended(86.27)thattheCommissionshouldhaveadequatefundinginordertobe able toproperlyconductitsfunctionsandactivities.
Need tohonourduediligenceobligations
Humanrightsjurisprudenceconcerningthedoctrineof‘duediligence’elaborateson
Australia’sobligationsconcerningtherighttolife.Aduediligencestandard
servesasatoolforrights-holderstoholdduty-bearersaccountablebyproviding an assessmentframeworkforascertainingwhatconstituteseffectivefulfillmentofthe obligation,andforanalyzingtheactionsoromissionsofthe
10 See among other instruments, Article 26, International Covenant on Civil and Political Rights, opened
forsignature 16 December 1966, 999 UNTS 171 (entered into force 23 March 1976).
11 See among other instruments, Article 26, International Covenant on Civil and Political Rights, opened
forsignature 16 December 1966, 999 UNTS 171 (entered into force 23 March 1976).
12 Article 17, International Covenant on Civil and Political Rights, opened for signature 16 December
1966,999 UNTS 171 (entered into force 23 March 1976); Article 10, International Covenant on
EconomicSocial and Cultural Rights, opened for signature 16 December 1966, 999 UNTS 3 (entered into force 3 January 1976).
13 Article 12, International Covenant on Economic Social and Cultural Rights, opened for signature 16
December1966, 999 UNTS 3 (entered into force 3 January 1976).
14 Seeamong other instruments, Article 2, International Covenant on Civil and Political Rights, opened
forsignature 16 December 1966, 999 UNTS 171 (entered into force 23 March 1976).
15 ConcludingObservations of the Committee against Torture, Australia, 40th Session,22 May 2008, CRC/C/AUS/CO/3; Concluding Observations of the Committee on Economic, Social and Cultural
Rights,Australia, 42nd Session,12 June 2009, E/C.12/AUS/CO/4.
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duty-bearer.16
Underinternationalhumanrightslaw,Australiahasanobligationtorespect,protectandfulfil thehumanrightsinthetreatiestowhichit isasignatory.‘Respect’requiresAustralia torefrain frominterferingdirectlyorindirectlywithhumanrights,while
‘protect’includestheobligationtotakemeasurestopreventthirdpartiesfrom interfering withhumanrights.
Theobligationto‘fulfil’containsfurtherobligationstofacilitate,provideandpromotehuman rights,andthusrequiresAustraliatoadoptappropriatelegislative,administrative,budgetary, judicialandothermeasurestowardsthefullrealisationofhumanrights.17
Courts,police,socialservices,andanyotheragenciesdesignatedbythefederalGovernment tohaveresponsibility,areunderadutytoensurethatallappropriate,reasonablestepsare takentoprotectindividualsfromthreatstotheirlife,threatsofinhumananddegrading treatmentorthreatstotheirmoralandphysicalintegrity.TheCommonwealth Government cannotdelegateitsultimateresponsibilitytoexercisethis duediligence.18
Australiaisthereforerequiredtonotonlymakelegalavenuesaccessibleforfamilymembers whohavelostlovedones,buttotakepositiveaction–actionnecessarytoprotect therightto lifeofallpersons.Thefocusofassessmentofwhethertherehasbeen sufficientduediligence is‘analysisofresultsandeffectiveness’.19
AsthissubmissionfocusesontheplaceofcoronialsystemsinAustralia’sproposedNational HumanRightsActionPlan,weexplainbelowhowtheroleofcoronersandthe functionof deathpreventionarerelevanttoAustralia’shumanrightsobligations.
Role ofcoroners
Coronersarerequiredtodiscoverthetruthaboutadeath,includingnotjustitsimmediate but alsoitsunderlyingcauses.20Inanybestpracticemodel,inquests,andparticularlycoronial recommendations,haveapreventativerole,21inproducinglong-
16 SpecialRapporteur on Violence Against Women, Its Causes and Consequences,Summary Paper on the Due Diligence Standard for Violence Against Women(2011)
17 Committeeon Economic, Social and Cultural Rights, General Comment 14, The Right to the Highest
AttainableStandard of Health, UN Doc E/C 12/2000/4 (2000), para 33.
18 UNCommittee on the Elimination of All Forms of Discrimination Against Women, General
RecommendationNo. 19 (11th session, 1992); Velasquez-Rodriguez v Honduras, judgment of 29 July,
1988,Inter-Am. Ct. H.R. (ser. C) No. 4, para 172; Maria da Penha v Brazil, Case 12.051, Report No.
54/01,Inter-Am. Ct. H.R., Annual Report 2000, OEA/Ser.L/V.II.111 Doc.20 rev. (2000).
19 SpecialRapporteur on Violence Against Women, Its Causes and Consequences,Summary Paper on the Due Diligence Standard for Violence Against Women (2011)
20 GraemeJohnstone, ‘An Avenue for Death and Injury Prevention’ in Hugh Selby (ed),The Aftermath of
Death(1992) 140, 145.
21 RoyalCommission into Aboriginal Deaths in Custody(‘RCIADIC’) National Report Vol 1 (1991), [4.7.4]; Graeme Johnstone, ‘An Avenue for Death and Injury Prevention’ in Hugh Selby (ed),The
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termsolutionstoanysystemicproblemsattheheartofthedeath.22Systemicissuescan arisefromcontextsasdiverseasthoseinvolvingthetreatmentofpersonsincustody and care,faultyproducts,medicallyrelateddeaths,industrialaccidents,orthe waythattheState respondsto domestic/familyviolence.
Themoderninquest’sfundamentalguidingprincipleshouldberespectforandprotectionof humanlife.Thisprincipleshouldguideacoroner’sfindingsastothecause ofadeath,commentsaboutresponsibilityforthedeathandrecommendationsto avoidfuturedeaths. Respectforandprotectionofhumanlifeasaguidingprincipleof coronialinquestsfrequently requiresinquiryintosystemicfailure,identificationofinstitutionalresponsibility,and appropriatelydirectedpracticalrecommendations.
Withrespecttocoronialinvestigations,therighttolifehasbeeninterpretedas encompassing thefollowingminimumrequirements:
•theinvestigationmustbeindependent;
•theinvestigationmustbeeffective;
•theinvestigationmustbereasonablyprompt;
•theremustbeasufficientelementofpublicscrutiny;
•thenextofkinmustbeinvolvedtoanappropriateextent;and
•theStatemustactofitsownmotionandcannotleaveit tothenext ofkintoconduct anypartoftheinvestigation.23
TheinquestintoMrWard’sdeathconductedbytheWesternAustraliaStateCoroner,Alistair Hope,providesabestpracticeexampleofmoderncoronialprocess.24TheState Coroner’s investigations,findings,wide-rangingrecommendationsandreportraisedandrespondedto systemicfactorsthatcontributedtoMrWard’sdeath,andfrom whichlessonsmaybelearned toavoidfuturedeaths.
EvidenceofAustralianhumanrightsviolationsconcerningtherighttolife
ThereisawealthofpublishedinformationthattheBaselineStudyshouldrefertoin documentingAustralia’shumanrightsviolationsconcerningtherighttolife.Asmallsample includesthefollowingreports,whichthemselvesalsorefertoavastrangeofauthoritative sources:Freedom,Respect,Equality,Dignity:Action–NGOSubmission totheHumanRights Committee(September2008);25theNationalReport oftheRoyalCommissioninto AboriginalDeathsinCustody(1991);theLaw
Aftermathof Death (1992) 140; James Reason, ‘Human Error: Models and Management’ (2000) 320
BritishMedical Journal 768.
22 DavidRanson, ‘The Role of the Pathologist’ in Hugh Selby (ed),The Aftermath of Death (1992) 80,
120-21.
23 Ron the Application of Amin v Secretary of State for the Home Department [2004] 1 AC 653, 25, 43,
44,50, 51; R on the Application of D v Secretary of State for the Home Department[2006] All ER 946, para 9(iii); Jordan v United Kingdom(2001) 37 EHRR 54, para 105-9; Leslie Thomas, Adam Straw and Danny Friedman, Inquests: A Practitioner’s Guide (2nd Ed, 2008), 360-79.
24 StateCoroner of Western Australia, Findings and Recommendations of the Inquest into the Death of
MrWard, 12 June 2009.
25 at 29 August 2011. See especially 64-66, 72-84.
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ReformCommissionof WesternAustraliaDiscussionPaper,ReviewofCoronial Practice inWesternAustralia(June2011);theJointNGOSubmissiontotheUniversal PeriodicReviewofAustralia(July2010,especially4);andtheJointAboriginalandTorres StraitIslanderLegalServicesUPRSubmission(2011).26
Thesereportsdocumentthewaysinwhichformsofstructuralinequalityanddisadvantagecontributetoadisproportionatenumberof deaths,includingdeathsof:peopleinpolicecustody andprison;peoplewithmentalillness;womenkilledbymalepartners; migrantsfromCALD communities;asylumseekersandrefugees;youngpeople; andpeoplewithdisabilities.
Oneexample,outofmanypotentialillustrations,demonstratessomeofthehumanrights implicationsandtheirconnectiontothecoronialsystem.
Example:ThedeathofPaulCarter
PaulCarterwasanAboriginalmanwithacognitiveimpairmentandahistoryofmentalillness andsubstanceabuse.On7August2006hediedafterbeinghitbyatruck ontheSturt Highway,12kmoutofMildura.Earlierthatday,Paul’sbrotherhaddied unexpectedlyfroman epilepticseizure.Paulhadspentmuchofthedaywithhisfamily mourninghisbrother’sdeath, andthenwenttohisgirlfriend’shousewherethe
policewerecalledlaterinthenight.
ItwasunderstoodthatthepoliceweretakingPaultohisfather’shouse,buthewasdropped offonthehighwayabout13kmaway,whereinthedarkandcold,withnofootpath andunder theinfluenceofgriefandalcohol,heranintothepathofthetruck. TheCoronerfoundthatit ‘goeswithoutsayingthathadPaulbeendeliveredtohis father’shomethatnight,hewouldnot havebeenatriskofrunninginfrontofa
truckontheSturtHighway.’27
Aspartofourargumentaboutwhatisneededforeffectivedeathpreventioninorderfor the AustralianGovernmenttofulfilitsobligationsconcerningtherighttolife,wealso give examplesofsystemfailureinthelastsectionofthissubmission.
MeasuresneededtoaddressAustralia’shumanrightsobligationsconcerningthe righttolife
AraftofmeasuresisnecessaryforAustraliatogenuinelyrespect,protectandpromote the righttolife.TheAustralianGovernmentisobligatedviaduediligencetodo allit reasonably cantopreventavoidabledeaths.Actionmustincludeeffectivepolicy formulationbasedonan understandingofthedemographics,patternsandrisk
26 at 29 August 2011.
27 StateCoroner of Victoria, Inquest into the Death of Paul Wayne Carter, 13 May 2009, 40.
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factorsofparticulartypesofdeaths;andthetranslationofthatpolicyintopractical initiatives.
Systemicinequalityisakeyfactorinmanypreventabledeaths.Thisisevidentinrelationto theshamefullyhighnumberofdeathsofAboriginalandTorresStraitIslanderpeoples, particularlydeathsincustodyand,forwomenespecially,deathsfrom familyviolence.Despite overwhelmingevidenceandpracticalrecommendationson whatisrequiredfrominvestigations suchastheRoyalCommissionintoAboriginalDeaths inCustody,suchdeathscontinue.This factprofoundlyillustratesthepresentsystemicfailuretoredresstheongoingimpactof colonialism,racism,misogynyandeconomic andculturaldispossessiononAustralia’sfirst peoplesandotherdisadvantaged communities.
Oursubmissionfocusesononlyonestrategy,theneedforeffectiveand‘joinedup’coronialsystemsandresponsesacrossAustralia.Thismustbeaccompaniedbybestpracticesupportandsensitivelyfacilitatedparticipationoffamiliesininvestigations,inquestsandallother aspectsoftherequiredsystemicresponse.
Resourcing ofcoroners
Acrucialfactorinwhetherrecommendationsaremadeinaparticularinquestisthatwhile coronersareindependentjudicialofficerswhooftenhavepowertoobtaindocuments and answerstoquestionsaboutadeathfromgovernments,corporationsand individuals; coroner’s officesareusuallyunder-resourced,withlittleassistanceprovided tohelpthem compiletheirfindingsandrecommendations.
Thepreventiongoalwouldbemetmoreeffectivelyif coronershadaccesstomoresystematic trainingandresourcestoassistthemwiththeformulationanddistributionof recommendations,supportedbysystematicdataandresearchabletobeeasily
accessedacrossjurisdictions.
RECOMMENDATION1
TheCommonwealthGovernmentshouldworkwithstateandterritorygovernmentstoenable eachjurisdictiontoeffectivelyrecognisetheinternationalhumanrightsobligationtorespect, protectandfulfiltherighttolifebyintroducing,asappropriate,amendmentstocoronial legislationsothatcoronialinvestigationisindependent,
appropriatelyandadequatelyresourced,andconsiderssystemicissues.
Aspartoftherecognitionoftherighttolife,wheretherighttolifeiscentraltoaninquest, familymembersmusthavegenuineandeffectiveaccesstolegalaidatalevel thatis consistentwiththeleveloflegalrepresentationaccordedtogovernmentandother institutionalpartiesintheinquest.
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The needforeffectivedeathprevention
Coroners’recommendationscanonlysavelivesif theyarerespondedtobytheagencies and entitiesresponsible.Effectivedeathpreventionalsorequiresasystemin whichresponses tocoronialrecommendationsaretrackedandchangesareimplemented which addressthesystemicfactorsidentifiedbycoronerstobeattheheart ofthedeath.
Families,advocates,researchersandothersconcernedwithsocialjusticealsodesire a publiclyaccountablecoronialsystemthatconsistentlyproducescomprehensive findingsand appropriatelytargetedrecommendations.Theyneedtoknow thatthegoalofpreventionis beingserved,andconsequentlyneedinformationabout whatrecommendationshavebeen made,theresponsesandassociatedreasoning ofagenciesandentities,how recommendationsarebeingimplemented,andhowimplementationwillbemonitoredto ensurethatavoidabledeathsareprevented inthefuture.
Asonebereavedfamilymemberhasexpressedit:
Putyourselfintothesituationofafamilythathasjustlostsomeone.Whyputourselves throughthisanyway?.. .[I]t isahardshipreadingthrougheverydetailin acoronial inquest,butif attheendofthedayyouknowthat,‘Such-and-such happened, thatiswhy yoursonisdead’,thenallright.I knewthreeandahalfyearsagothatthedeath shouldhavebeenavoidable.Therewasnoneedforanyone toploughthrough11days ofevidenceforthat.Butif somethingelsecomes outofit, if systemscanchange,then yes,it isworthdoing.28
Buthowdofamilymembers,socialjusticeadvocatesandthegeneralpublicfindoutwhether andwhen‘somethingelsecomesoutofit’?
TheNationalCoronersInformationSystem(NCIS)isaveryvaluabletoolandasignificant stepforwardinthepreventionofuntimelydeath.Itsprimaryroleistoassist coronersby providingthemwiththeabilitytoreviewsimilarpreviouscoronialcases. However,NCISdata, includingcoronialfindingsandrecommendations,isnotpubliclyavailable.TheNCISalsodoes notholddataabouttheimplementationofcoronialrecommendations.Thismeansthatit isverydifficultforresearchers,let
alonethegeneralpublic,toassesstheimpactofcoronialrecommendationsuponthe preventionofdeathsinthevariousAustralianjurisdictions,eithergenerallyorinanyparticular kindofdeath.
Theonlyresearchtodatethathasexaminedimplementationofcoronial recommendationsinallAustralianjurisdictionsfoundthattherewere
28 MrsM. Kaufmann, mother of Mark who was fatally shot by police,Minutes of Evidence, 22 August
2005,68-9, Law Reform Committee, Parliament of Victoria,Inquiry into the Review of the Coroners Act
1985 9
September2009.
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recurringinstanceswherecoronialrecommendationshadnotbeencommunicated or hadbeenmiscommunicated,orwerelostwithinbureaucraticprocesses.29
Anumberoffactorsweresignificantinwhetherarecommendationwasimplemented:
• whetherpriorcoronialrecommendationsarisingfromsimilardeathsweredrawn to theattentionoftherelevantauthorities;
• whetherresponsesfromtargetedorganisationsweremandatory;and
• whetheraproactivesystemforreviewofrecommendationsexistedwithinthe targetedorganisation.30
AstheAustralia-widestudyfound,withinanyparticularjurisdiction,recommendationsmay notbeimplementedintimetopreventothersimilardeaths-or mayneverbeimplemented. Thepresentpatchworksystemalsomeansthat
governmentandotheragenciesinonejurisdictionareunlikelytolearneffectivelyandin a timelywayfromadeath,orevenapatternofdeaths,inanotherjurisdiction.
Failuretobridgethegapbetweencoronialrecommendationsandimplementation,andto applythelessonsfromrecommendationsconcerningearlierdeathstosimilarsubsequent situations,isevidentevenincontextswherethereareclearnationalramificationsorwherea nationalbodyisimplicatedintherecommendations.
Thisfailureisbestillustratedbythefateofmanyoftherecommendationsofthe
RoyalCommissionintoAboriginalDeathsinCustody.
Royal Commissioninto AboriginalDeathsin Custody
TheRoyalCommissionintoAboriginalDeathsinCustodywasestablishedin1987toaddress concernsaboutthenumbersofAboriginalandTorresStraitIslanderpeoplesdying inprisons, policecustody,andjuveniledetentioninstitutions.TheRoyalCommission’s 1991National Reportconcludedthatthehighdeathratewasdueto
thegrossover-representationofAboriginalandTorresStraitIslanderpeoplesin custody.31TheRoyalCommissionthereforeexaminedtheunderlyingreasonsforthis, includingprofoundsocial,economicandculturaldisadvantage.
29 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review4, 5. The study tracked the response of government agencies to 484 coroners' recommendations in 185 inquests around Australia,
mostlyin 2004.
30 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review4, 12.
31 RCIADICNational Report Vol 1 (1991).
10
Aspartofitsinvestigation,theRoyalCommissionobservedthattherewasa
pervasiveandtroublingfailureofthecoronialstructureineverystateand territory tosupplythecriticalanalysisneededtouncoverthereasonsfor Aboriginal deathsincustody.32
Thiswascoupledwithafailureofthecoronialsystemasawholetohelpprevent
AboriginalandTorresStraitIslanderdeaths.33
TheNationalReportofferedpracticalsuggestionstoreducetheriskof AboriginalandTorres StraitIslanderincarcerationanddeathsincustody.34ofthe339recommendationsconcerned reformofthestateandterritorialcoronialsystems.Inessence, theyurgedthatthecoronial systembestrengthenedsothatcoronerscouldbe empoweredtoeffectivelyaddresssystemic prevention.
FiveoftheRoyalCommission’srecommendationsspecificallyconcernedtheneedfor mandatoryresponsestocoronialrecommendations:
Recommendation14
ThatcopiesofthefindingsandrecommendationsoftheCoronerbeprovidedby the CoronersOfficetoallpartieswhoappearedattheinquest,totheAttorney-General or MinisterofJusticeoftheStateorTerritoryinwhichtheinquest wasconducted,tothe MinisteroftheCrownwithresponsibilityfortherelevant custodialagencyor departmentandtosuchotherpersonsastheCoroner deemsappropriate.34
Recommendation15
Thatwithinthreecalendarmonthsofpublicationofthefindingsandrecommendations oftheCoronerastoanydeathincustody,anyagencyordepartment towhichacopy ofthefindingsandrecommendationshasbeendelivered bytheCoronershallprovide, inwriting,totheMinisteroftheCrownwith responsibilityforthatagencyordepartment, itsresponsetothefindingsand recommendations,whichshouldincludea reportastowhetheranyactionhas beentakenorisproposedtobetakenwithrespect toanyperson.35
Recommendation16
ThattherelevantMinistersoftheCrowntowhomresponsesaredeliveredby agencies ordepartments,asprovidedforinRecommendation15,providecopies of eachsuchresponsetoallpartieswhoappearedbeforetheCoronerat theinquest,to theCoronerwhoconductedtheinquestandtotheStateCoroner. ThattheState Coronerbeempoweredtocallforsuchfurther
32 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review4, 6.
33 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review 4, 6.
34 RCIADICNational Report Vol 1 (1991), 172.
35 RCIADICNational Report Vol 1 (1991), 172.
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explanationsorinformationasheorsheconsidersnecessary,includingreportsas to furtheractiontakeninrelationtotherecommendations.36
Recommendation17
ThattheStateCoronerberequiredtoreportannuallyinwritingtotheAttorney- General orMinisterforJustice(suchreporttobetabledinParliament),astodeaths in custodygenerallywithinthejurisdictionand,inparticular,astofindingsand recommendationsmadebyCoronerspursuanttothetermsofRecommendation13 aboveandastotheresponsestosuchfindingsandrecommendationsprovided pursuanttothetermsofRecommendation16above.37
Recommendation18
ThattheStateCoroner,inreportingtotheAttorney-GeneralorMinisterforJustice,be empoweredtomakesuchrecommendationsastheStateCoronerdeems fit with respecttothepreventionofdeathsincustody.38
WhileanumberoftheRoyalCommissionreformshavenowbeenimplemented,manyhave not.Inrelationtothecoronialrecommendationissues,theCommonwealth Governmentand allStateandTerritorygovernmentssupportedRecommendations14,15,17and18. Recommendation16,essentiallydealingwithkeeping theinquestparties‘intheloop’in relationtoresponses,andwithcoronialfollow-up ofresponses,wasnotendorsedbySouth Australia,TasmaniaortheNorthern Territory.39Twentyyearslater,noneof Recommendations14-18hasbeenimplemented inasystematic,nationwidemanner.
TheWAStateCoroner,AlastairHope,handingdownhisfindingsandrecommendationsin theinquestintothedeathofMrWard,hassupportedthecontinuingrelevanceoftheRoyal Commission’srecommendations,drawinguponthem tounderpinhisviewofbestpractice coronialinvestigationanddeathprevention.40
Thefindingsfromthenationalstudyexaminingimplementationofcoronial recommendationsechotheRoyalCommissioninsuggestingthatmandatoryresponses wouldimproveboththecommunicationandimplementationofcoronial recommendations.41Jurisdictionsalsoneedtohaveaneffectivesystemformonitoring recommendations,responsesandappropriateimplementation.Governmentagenciesand otherrelevantentitiesmustbeencouragedtodevelop
36 RCIADICNational Report Vol 1 (1991), 173.
37 RCIADICNational Report Vol 1 (1991), 173. Recommendation 13:That a Coroner inquiring into a death in custody be required to make findings as to the matters which the Coroner is required to
investigateand to make such recommendations as are deemed appropriate with a view to preventing further custodial deaths. The Coroner should be empowered, further, to make such recommendations on other matters as he or she deems appropriate (RCIADIC National Report Vol 1 (1991), 172).
38 RCIADICNational Report Vol 1 (1991), 173.
39 Formore detail, see Ray Watterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of Indigenous Death’ (2008) 12 (6)Australian Indigenous Law Review4, 22.
40 State Coroner of Western Australia, Findings and Recommendations of the Inquest into the Death of
MrWard, 12 June 2009.
41 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review4, 12.
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theirowninternalsystemsfordealingwithrecommendations,thatentailclearlinesof responsibility.
Victoriahasnowmandatedagencyandotherentityresponsestocoronial recommendations,42makingit onlythethirdAustralianjurisdictiontodoso.Without mandatoryresponses,agenciescanignoreorevenloserecommendationswithouthavingto informthecourt,thedeceased’sfamilyorthepublicoftheirresponse.43
RECOMMENDATION2
TheCommonwealthGovernmentshouldworkwithstateandterritorygovernmentsto harmonise corebestpracticesothatallpertinentStateandTerritorylegislationisamended to requiretherelevantgovernmentsandotherentitiestorespondto
coronialrecommendationswithinasettimeframe.
Joined upjustice
Thesystemicfailurethatledtothedeathisoftenperpetuatedduetoasecondtierof systemic failure–aninabilityofgovernmentsandotherentitiestorespondeffectively.Inthese contexts,coronialrecommendationsconcerningearlierdeathsmight havesavedlater livesif theyhadbeenimplemented.
Thissecondsystemicfailureismostclearlyevidencedinresponsestothosedeathswhich continuetoformarepeatingpatternirrespectiveofstateandterritoryboundaries, suchas deathsassociatedwith:thetransportationofdetainedpersons,thepresenceofhanging pointsinprisons,policeshootings,orinstitutionalfailuretoeffectivelyinterveneinfamily violence.
Tomorestarklyhighlightthepresentpiecemealapproachtodeathpreventionwherelessons haveoftenfailedtobelearnedbothwithinandacrossstateandterritoryjurisdictions,wedraw onasomewhatdifferentbutequallytragicpattern,ofchilddeaths duetostrangulationbyblind cords.
Blindcorddeathsperhapsbestillustratewhyreformofthebroadersystemwhichanalyses and respondstodeathsisalsonecessary.Theblindcordcasesclearlyshow thegapsinthe systemthatcanperpetuatethepatternofdeathswhenresponses tocoronial recommendationsarenotonlynon-mandatory,butalsoarenotpartofacoordinated nationwideresponse.
42 CoronersAct 2008 (Vic) s 72.
43 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ 2008 12(2) Australian Indigenous Law Review4.
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Blindcorddeaths–examplesofdoublesystemfailure
On28July2004,theVictorianStateCoronerbroughtdownhisfindingsinrelationtoan infant whodiedwhenhisneckbecameentangledinaloopedblindcord.TheCoroner adoptedthe recommendationsofaTasmanianinquestconcerninganotherdeath inalmostidentical circumstanceson19December2003:
• apubliceducationprogramshouldbeimplementedwhichhighlightstheriskand informsthecommunityaboutmethodstoaddressthehazard;
• aneffectiveapproachshouldbeadoptedtorendersafeblindsandcurtainswhich arealreadyinstalled;and
• amandatorysafetystandardshouldbeimplementedin[Victoria]withregardto the supplyofwindowcoveringswithcordstoaddresstheriskofinfantstrangulation.
On1March2007,13-month-oldNicholasEspositodiedinSouthAustraliaasaresultof hanging.44Thepost-mortemreportfromforensicpathologistProfessorRogerByard saidthat hangingfromcordsisarecognisedriskwhencotsareplacednexttoblinds. Inhisfindings, the DeputyStateCoroner(DSC)notedthatProfessorByardhad alsogivenevidenceata previousSouthAustralianinquestintothedeathofa
15-month-oldtoddlerinNovember1999byhanginginvolvingablindcord.
Asaresultofthe1999death,theformerSouthAustralianStateCoroner,WayneChivell, had calledforapublicwarningtobegiventotheparentsofyoungchildrenabout therisks involvedinallowingthemtohaveaccesstoropesorcordswhicharelong enoughtogo aroundthechild’sneck.Hesaidthatparentsshouldensurethatcurtaincordsarekeptoutof thereachofsmallchildrenandthattheyshouldbeprovided withadviceandassistanceabout howtoavoidtheserisks.
InNicholasEsposito’sinquestmorethaneightyearslater,theDSCsaidthatchildblind cord deathswerepreventable.Howeverhepointedoutthatover2000-2008there hadbeeneight coronialreportsfromotherStatesorTerritoriesofinfantblindcord deaths.Twoofthese deathsweretheTasmanianandVictoriandeathsdescribed above.TheDSCnotedthat these twodeathswerethesubjectofcoronialfindingsandrecommendationsthatwereinthe publicdomainandwereverysimilarto thosemadeinthepresentinquestintothedeathof NicholasEsposito.
TheDSCalsofoundthatwhileNewSouthWales,Queensland,Tasmania,Western Australia andtheACTnowhadblindcordregulationsinplace,SouthAustraliaandVictoria didnot.45ThedifferencebetweenTasmaniaandVictoriainrelationtothelegislation, despitetwoverysimilardeaths,appearslargelyduetothemedia
44 SADeputy State Coroner Anthony Schapel, Findings into the Death of Nicholas Esposito, 15
December2007.
45TheDSC noted that product safety regulators across Australia were undergoing a process of harmonising all applicable legislation, which had been agreed to by all State, Territory and
CommonwealthMinisters and would include safety standards and bans. The nationwide system was
expectedto be in place by mid 2009.
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coverageinTasmaniaastheresultoftheactivismofthemotherofthechildwhodied there.46
Theblindcorddeathsstarklydemonstratetheabsenceofclearrecommendationand implementationpathwaysacrossstatesandterritories.Agenerallackofsystematicmonitoring alsomakesit difficulttolearnfrompatternsofdeaths,particularlyacrossAustralian jurisdictions.47Thissituationcreatesaseriousobstacletoconsistentbestpracticeininquests, topublicaccountability,toattemptsatsystematicresearch,andultimatelytomore effectivedeathpreventionacrossAustralia.
Simplyput,if statesandterritorieshaveaneffectiveresponsesystemandareabletolearn fromeachotherwhensimilardeathsoccurindifferentjurisdictions–whetherthose deaths occurinprisontransport,areduetoavoidableaccidents,ortakeplacein anyotherpreventable context–peoplewillnotcontinuetodieasaresultofafailure to‘joinup’justice.
In2008,thethenfederalMinisterforHomeAffairs,theHonourableBobDebus,expressed hishopethatcoronialrecommendationsandthepreventionofavoidabledeaths wouldbe addedtotheagendaoftheStandingCommitteeofAttorneys-
General.48
RECOMMENDATION3
TheCommonwealthGovernmentshouldworkwithstateandterritorygovernmentstoachieve auniformnationalcoronialpublicreportingandreviewschemeforcoronial
findingsandrecommendationswhich:
guaranteesthatallcoronialrecommendationswillbeconsideredandrespondedtoby the governmentagenciesandanyotherentitiesorpersonstowhomtheyare
directed;
providesreadypublicaccesstoallcoronialfindings,recommendationsand responses;
recordsandmakespubliclyavailable(includingviaaCoronersAnnualReporttoParliament andontheInternet)whetherornotcoronialrecommendationshavebeenimplemented by responsiblegovernmentagenciesandotherentities;
enablesevaluationof theimpactofcoronialrecommendationsuponthepreventionofdeaths;
adherestotimelinessateverystepoftherecommendationsprocess;and
46 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ (2008) 12 (6) Australian Indigenous Law Review4, 17-18.
47 RayWatterson, Penny Brown and John McKenzie, ‘Coronial Recommendations and the Prevention of
IndigenousDeath’ 2008 12(2) Australian Indigenous Law Review4.
48 HonBob Debus, ‘Foreword’ (2008) 12 (6) Australian Indigenous Law Review4, 1.
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providesfeedbacktofamilies(includingacopyofrecommendationsandresponsesto families,otherpartiesandlegalrepresentatives)ateverystepofthe
recommendationsprocess.
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