Health
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.
Key points:
- The report found coroners’ recommendations were falling on deaf ears
- It also found the coronial system was alienating for many First Nations people
- It called for “radically different coronial approaches” to improve the situation
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.
“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.
Some coroners highlighted recommendations repeatedly made – including eliminating ligature points in custodial settings – showed that important and potentially life-saving advice was repeatedly ignored by government agencies.
“One coroner said they felt they could not in good conscience make further recommendations about hanging points in prisons in the face of so little action,” the report stated.
“Another had been asked to consider recommending the employment of more Indigenous health workers in prisons following a death in custody, but said he did not do so because they knew this workforce could not be recruited in the region in question.”
CBPATSISP director professor Pat Dudgeon, who co-authored the report, said Indigenous people who have been through the process were equally frustrated.
“You put energy and hope into a process and there’s a good outcome, but it doesn’t go anywhere,” the Bardi woman said.
“So, I think that it’s not only the coroners that become frustrated, but for many Indigenous people, it’s the same old story that’s repeated.
“How many times do you shine light on an issue before it’s dealt with?”
‘Radically different’ approach needed
The report recommended every state and territory coronial jurisdiction should employ Aboriginal and/or Torres Strait Islander people in court support and family engagement roles.
It also called for additional resources towards training and development for coroners and court staff and an establishment of a wider Aboriginal and Torres Strait Islander suicide review network.
More recently, suicide registers have been established in some jurisdictions, including Victoria, which are primarily intended as early alert systems for suicide clusters.
“Coroners, justice departments and governments at all levels should, out of respect and in a spirit of reconciliation, be willing to consider radically different coronial approaches that better meet the needs of Aboriginal and Torres Strait Islander people,” the report said.
Victoria and NSW have established dedicated Indigenous coroner’s court and family support roles, while Queensland and the ACT have funded similar roles.
But in WA, those positions are pending appointment only at the State Mortuary and Bereavement Centre – not the court itself.
“I think it will always come back to government and government funding the coroner’s office,” Ms McKenna, who co-authored the report, said.
“In a way that is going to be reflective of the recommendations that have been made by the participants who’ve been engaged in this project.”
The WA Department of Justice and Coroners Court have been contacted for comment.
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