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Coroners frustrated recommendations on Indigenous suicide ignored by government, report shows

Coroners frustrated recommendations on Indigenous suicide ignored by government, report shows


Coroners around Australia are frustrated their potentially life-saving recommendations to prevent Indigenous suicide are being routinely ignored by the government, a new national report has found.

The research by the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) examined state and territory coroner’s courts’ responsiveness to First Nations families who had lost a loved one to suicide.

It involved interviews with coroners, their staff and Indigenous people with lived experience, who called for greater accountability on the implementation of recommendations from inquests and other inquiries.

The report also found the current coronial system was alienating for many First Nations people and coroners wanted more cultural training to improve the experience for Indigenous people going through it.

‘Another layer of grief’

Vicki McKenna, manager of the Aboriginal and Torres Strait Islander Lived Experience Centre with the Black Dog Institute, described the coronial process as “another later of grief” for most Indigenous families.

A woman smiles for the camera.

Vicki McKenna says the language that coronial reports are written in leaves Indigenous families struggling for closure. (ABC News: Daryna Zadvirna)

“There’s a lot of hurt that comes with that, because families feel like feel like they’re dismissed,” the Yawuru and Bunuba Jarndu woman said.

“Having none of this contact or communication with the current coroner’s office … makes the situation for them more complex.”

Many lived experience interviewees pointed to systemic issues such as lack of cultural understanding, communication, and financial support.

“Because of the language that is used and in the way that these reports are written, it leaves our families still struggling to understand,” Ms McKenna said.

“That doesn’t bring complete closure to our families.”

One coroner described the First Nations experience of courts in Australia as “almost exclusively negative”.

“So, coming to a court there’s an expectation something bad is going to happen to that family,” they said.

“And why would that be any different just because it’s a coroner’s court?”

Another coroner working in a remote area said coronial systems needed to adapt their processes to local cultural needs, while several described how they now routinely visit communities ahead of an inquest to gain a more thorough understanding of cultural needs.

Recommendations repeatedly ignored

The suicide rate among Aboriginal and Torres Strait Islander adults is double that of other Australians, and among children it is four times as high.

Coroners told researchers there was insufficient emphasis on applying inquest recommendations and administrative findings systematically in Indigenous suicide prevention.




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