1. 1 The Coroners Court: roles, reflections and death prevention State Coroner Judge Jennifer Coate

2. 2 Preamble to Coroners Act 2008 The coronial system of Victoria plays an important role in Victorian society. That role involves the independent investigation of deaths and fires for the purpose of finding the causes of those deaths and fires and to contribute to the reduction of the number of preventable deaths and fires and the promotion of public health and safety and the administration of justice.

3. 3 Reportable deaths Defined in the 2008 Act - s.4(1). Two requirements: 1.the death must in some way be connected with Victoria 2.The death must meet one of the following criteria: – Where the person died unexpectedly & the cause of death is unknown; – Where the person died from an accident or injury; – Where the person died in a violent or unnatural manner; – Where the person was ‘held in care’ (e.g. by Dept of Human Services, under the Mental Health Act) or in custody immediately before they died; – Where a doctor has been unable to sign a death certificate giving the cause of death; or – Where the identity of the person who has died is not known. – Where the person died during / following a medical procedure.

4. 4 Coroners’ fire jurisdiction The CFA or MFB may request a coroner to investigate a fire Coroner must investigate unless not in the public interest Any person can ask a coroner to investigate a fire but coroner can refuse with written reasons

5. 5 Consider

6. 6 Reportable deaths

7. 7 Role of the coroner The primary focus of the coronial investigation is not whether someone should face criminal or civil or disciplinary proceedings but rather, to investigate and analyse the circumstances surrounding the death to : Find identity, cause and circumstances AND look for any systemic failures that contributed to the death and endeavour to design remedial or preventative responses.

8. 8 Who are Coroners? The medical examiners of TV and Crime fiction VS Australian coronial system

9. 9 Commonly reported deaths In practice, deaths are reported for the following reasons: 1.The death is one due directly or indirectly to accident (incl. a fall) or injury. Includes all homicides, suicides and accidental deaths. Includes those resulting from drugs, poisons, heat, cold and electricity. Does not include ‘natural’ deaths following tobacco or alcohol abuse – for instance, carcinoma of the lung or cirrhosis of the liver, which should not be reported. 2.Deaths of people held in care. Includes people dying: in prison in police cells as a result of police action or while being detained 3.Intra or post procedural deaths – any death occurring during or after a medical procedure where the death is not expected by a medical practitioner. 4.The doctor does not think s/he knows the cause of death with sufficient certainty to sign the death certificate.

10. 10 Coroner vs criminal process Where prosecution is underway, Coroner waits Coroners are prohibited from making any statement that a person is or maybe guilty of a crime Coroner may notify DPP if he/she believes a crime may have been committed in connection with a death or a fire

11. 11 Extent of under-reporting In 2008, the Registrar of Births, Deaths & Marriages reported 808 deaths to the State Coroner because the death certificates disclosed information that indicates that the doctor should have reported the death and not completed a death certificate. By the time such deaths are reported the deceased has often been buried, and in some rare instances may lead to an exhumation being required. If the deceased has been cremated further examination of the deceased’s body is, of course, impossible.

12. 12 Duty to report deaths Coroners wait for a death to be reported to them. There is little, if any, proactive ability for a Coroner to seek out reportable or reviewable deaths. Whilst doctors must report reportable & reviewable deaths, any person who has reasonable grounds to believe that a reportable death has not been reported must report it to a coroner or the police.

13. 13 The Coronial Investigation

14. 14 Nature of the investigation Depending on the nature of the investigation, a range of information is collected on behalf of the coroner, most usually by Victoria Police. The Coroner may seek information from independent experts. A brief of evidence is prepared for the Coroner and contains the following (if available)— (a)a statement of identification; (b)any medical examination reports; (c)reports and statements and evidentiary material that the coroner believes is relevant to the investigation;

15. 15 Nature of the investigation Autopsies: An autopsy is a physical examination of a person’s body conducted by a pathologist who must his or her findings to the coroner. It can help explain the cause of death. Not every case requires an autopsy.

16. 16 Nature of the investigation Coroners have a considerable range of powers  To break, enter and search premises or authorise a member of the police force to do so and seize evidence  To direct a person at the premises to produce documents, operate equipment & access information from the equipment (e.g. computers).  A coroner may now order a person to provide answers to specific questions in a statement

17. 17 The Coronial Inquest

18. 18 The Coronial Inquest An inquest is a court hearing conducted by the Coroner, in which the circumstances surrounding a death are examined. Ideally inquests should be held with as little formality and technicality (as the interests of justice permit). Mandatory in certain circumstances eg. homicide, death in custody, identity unknown etc. Otherwise the coroner has a discretion as to whether an inquest will be held. Inquests are usually open to the public.

19. 19 The Coroners Act 2008  On 1 November 2009, the Coroners Act 2008 came into effect.  It established the Coroners Court of Victoria, which is the first Australian Court to be established as a specialist inquisitorial court.  Difference between inquisitorial court and adversarial /traditional court

20. 20 Distinguishing features of the Coroners Court Coronial inquests are not run in the same way as a criminal / civil trial. They are:  Inquisitional cf. Adversarial Classic features of the adversarial system: 1)Minimum intervention by the decision maker 2)Parties define the issues 3)Parties decide what evidence they will put before the judge 4)It is not a search for the truth of what happened The inquisitorial system of the Victorian Coroner: a)It is an inquiry into the truth of what happened b)Coroner at all times conducts the investigation c)Directs what witnesses he or she wants to be called d)Shapes and controls the issues e)Can and does question witnesses f)Discusses cases with investigators and even witnesses g)Not bound by rules of evidence h)Any person with sufficient interest may be granted a right to appear e.g. Law Reform Commission, etc.

21. 21 Not deciding legal rights It is not a court which decides legal liability.

22. 22 Coronial Findings At the conclusion of an investigation, a coroner prepares a written finding to establish wherever possible: – Identity of the deceased – Cause of death/fire And in some cases, the: – Circumstances surrounding a person’s death. – Causal relationship between the circumstances and death. A finding may also include comments &/or recommendations.

23. 23 The Coroner’s Comments The causal relationship in a particular case is explored in depth and broader issues raised: – Safety procedures & information provision. – Staff training & communication. – any problems in patient management & emergency protocol (e.g. in medical matters).

24. 24 The Coroner’s Recommendations A coroner may make recommendations on any matter connected with the death or fire including public health or safety or the administration of justice. To any Minister or public statutory authority or entity The Coroner's Prevention Unit (CPU) assists Coroners in relation to the formulation of prevention recommendations as well as help monitor and evaluate the effectiveness of the recommendations.

25. 25 Obligation to respond to Recommendations  Public statutory authorities & entities must provide a written response to the recommendations within 3 months  Coroner must publish on the internet  Findings, comments and recommendations made following an inquest will be published on the internet, unless otherwise ordered by a coroner.

26. 26 Thankyou