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Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
22
Inquest should not proceed in the absence of family of the deceased
That no inquest should proceed in the absence of appearance for or on behalf of the family of the deceased unless the Coroner is satisfied that the family has been notified of the hearing in good time and that the family does not wish to appear in person or by a representative. In the event that no clear advice is available to the Coroner as to the family's intention to be appear or be represented no inquest should proceed unless the Coroner is satisfied that all reasonable efforts have been made to obtain such advice from the family, the Aboriginal Legal Service and/or from lawyers representing the family.
The support provided by Koori Engagement Unit (KEU) has been instrumental for Aboriginal families. The KEU has also enhanced the capacity of VALS to represent our clients, by liaising closely with VALS lawyers in relation to all aspects of the coronial process. We strongly support the KEU being further embedded in the Court, with increased visibility over the coronial investigation and access to all information that is relevant for families in a timely manner.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 22 is to ensure that an inquest does not proceed without the deceased person’s family unless they choose not to attend.
Requirements outlined in the Coroners Act 2008 (Vic) and Practice Direction 6 closely align with the intent of this recommendation. The Act mandates that the senior next of kin and other interested parties are informed about the coronial process and given any related documents and information. Practice Direction 6 requires notification of the Victorian Aboriginal Legal Service (VALS) within 48 hours of a death, to ensure early legal advice and support is provided to families. The Coroners Koori Engagement Unit also keeps families informed and involved throughout the investigation, including coordinating hearing dates to enable family attendance.
There’s a clear connection between these actions and their impact. There was no recent evidence of inquests proceeding in the absence of family. Provisions in the Act, Practice Direction 6, and the practices of the Coroners Koori Engagement Unit results in the next of kin and family members being contacted and their advice sought throughout the coronial process, including in relation to inquests. However, VALS noted other issues faced by families where investigations of Aboriginal deaths in custody proceeded to inquest:
For those that do proceed, families frequently lack clarity on timeframes and do not receive timely access to the coronial brief.
We note concerns raised by community members and VALS regarding financial barriers that hinder families from regional or interstate locations from attending hearings and inquests in Melbourne. These costs, including travel and accommodation, can significantly limit families’ ability to participate in the inquest. Increased funding is needed to cover families’ travel and accommodation expenses.
Recommendation 22 remains relevant but given there was no evidence of inquests proceeding in the absence of family it was considered a low priority for further work in the context of other RCIADIC recommendations to improve coronial processes.
Priority for Further Work:
Low
Relevance and potential impact | |||||
|---|---|---|---|---|---|
Low (0-2) | Moderate (3-4) | High (5-6) | |||
Extent of action taken and evidence of outcomes | High (5-6) | ||||
Moderate (3-4) | |||||
Low (0-2) | |||||
Potential Actions for Further Work
Additional resourcing for Aboriginal Engagement Unit within the Coroners Court
Provide additional resources to the Yirramboi Murrup Unit to better support families with coronial processes.
Coroners Court call-over list for Aboriginal passings
Establish a monthly call-over list for all matters being dealt with by the Court when an Aboriginal person has passed away. The purpose of this list would be to provide regular updates to bereaved families and other interested parties about the progress of the investigation/inquest.
Government funding to support families’ attendance at inquest
Victorian Government to fund families travel and accommodation expenses to enable attendance at hearings, and inquest.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) emphasised the importance of involving the deceased's family in the inquest proceedings, recognising their inherent right to participate in the coronial process. Highlighting issues around timely notifications, legal representation, and addressing communication challenges in remote areas, the report proposed a procedural framework to inform families of their rights within a coronial inquest. Inquests should proceed only if the coroner is satisfied that diligent effort have been made to seek advice from the family and/or their legal representatives.
Actions Taken Since Last Review
Coroners Court of Victoria
Under the Coroners Act 2008 (Vic), the principal registrar must promptly provide prescribed information about the coronial process to the senior next of kin and other interested parties (often family members).
Coroners Court of Victoria
Since its establishment in 2019, the Coroners Koori Engagement Unit (now the Yirramboi Murrup Unit) has assisted Aboriginal families to navigate coronial processes by providing support and responding to their needs in relation to court procedures.
Aboriginal staff in the Yirramboi Murrup Unit provide cultural support and communicate directly with Aboriginal families throughout the coronial process. They facilitate family and community access to hearings, including participation via technological means, and assist with arrangements for families to attend court when needed.
In 2020, the State Coroner issued Practice Direction 6 to formalise a range of culturally safe practices implemented within Court processes by the Coroners Koori Engagement Unit. Practice Direction 6 includes several measures to strengthen support for families during coronial investigations into Aboriginal deaths in custody:
- Within 48 hours of a death, the Court will contact the Victorian Aboriginal Legal Service (VALS), so they can provide early legal support and advice to families.
- A directions hearing will be convened within 28 days of the death, to confirm the coroner’s investigator and due date for coronial brief and potential scope of inquiry.
- Court staff are to keep the family of the deceased informed of the progress of the investigation, including being consulted on proposed hearing and inquest dates.
- The Coroners Koori Engagement Unit will provide the deceased’s family with ongoing advice on coronial process throughout the investigation.
- A cultural brief will be prepared for the investigating coroner to ensure awareness of relevant cultural issues specific to the deceased and their community.
- Hearings will be convened in a culturally appropriate manner with acknowledgement of country, smoking ceremonies, in court display and use of culturally significant items, and appropriate warnings when names of deceased persons are used.
The State Coroner, Judge John Cain recognised the importance of supporting Aboriginal families throughout the coronial process:
The Court has an important role in independently investigating Indigenous deaths in custody – how we carry out this duty must recognise and respect the cultural needs of the families affected. This new practice direction will make the Court a safer and more supportive place for Indigenous families.
Troy Williamson, Manager, Coroners Koori Engagement Unit emphasised the need to listen and respond to the needs of Aboriginal families:
This practice direction gives Aboriginal people a voice in investigations into deaths in custody and ensures the Court is equipped with the cultural competency to support them. These reforms will reduce the trauma experienced by Aboriginal families as they deal with the grief of losing a loved one while navigating the coronial system.
Impact
Outputs
The Coroners Act 2008 (Vic) and Practice Direction 6 of 2020 support the intent of ensuring family involvement in inquests into Aboriginal deaths in custody. Section 8(d) of the Act requires families to be kept informed about the progress of the investigation, while Practice Direction 6 mandates ongoing consultation to support family participation, including around hearing dates.
Outcomes
There is no documented evidence of inquests being delayed due to uncertainty around family participation. The requirements of the Coroners Act 2008 (Vic), Practice Direction 6, and the practice of the Coroners Koori Engagement Unit suggest that families are routinely contacted and engaged throughout the coronial process.
However, community concerns expressed by VALS highlight that limited funding—particularly for families that reside interstate or in regional areas—can restrict meaningful participation. These financial and logistical barriers may impact families' ability to attend hearings, remain informed, and fully engage with the investigation into their loved one’s passing.
Community Views
Victorian Aboriginal Legal Service
The Coronial Council of Victoria completed a Review into Improving the Experiences of Bereaved Families with the Coronial Process. In their 2021 submission to this review, VALS acknowledged the importance of the Coroners Koori Engagement Unit (KEU):
The support provided by KEU has been instrumental for Aboriginal families. The KEU has also enhanced the capacity of VALS to represent our clients, by liaising closely with VALS lawyers in relation to all aspects of the coronial process. We strongly support the KEU being further embedded in the Court, with increased visibility over the coronial investigation and access to all information that is relevant for families in a timely manner.
Clear communication and timely access to information throughout the coronial process are essential to ensure that Aboriginal families who have lost a loved one are treated with dignity, respect, and cultural sensitivity. Early and consistent information helps alleviate grief and distress, allowing families to participate meaningfully in investigation and inquest processes.
Although the KEU plays a critical role in explaining the coronial process to Aboriginal families and providing information and updates throughout the process, there is a clear need for better processes to ensure that families and their legal representatives are provided with detailed information throughout the entire coronial process.
While recognising that the Coroners Act 2008 and Practice Direction 6 seek to uphold RCIADIC recommendations 21, 22 and 24 (among others), VALS noted that in practice Aboriginal families often face communication gaps and serious delays. Investigations can take years, with little information shared during this time, deepening existing distrust in the coronial system. If a case does not go to inquest, families are usually notified only via written correspondence. For those that do proceed, families frequently lack clarity on timeframes and do not receive timely access to the coronial brief.
Further challenges arise during the inquest process itself. Families and their legal representatives, such as those from VALS, report delays in receiving critical information, poor communication about key procedural steps, and insufficient responses from the Court. In some cases, decisions by the coroner are not communicated to the family or their representatives, adding to their distress and frustration.
To ensure clarity regarding each coronial process, as well as timely and proactive access to all relevant information, the Coroners Court should establish a monthly call-over list for all investigations and inquests into the death of an Aboriginal person. The aim of this list would be to update families and other interested parties on any developments in the investigation/inquest. The Victorian Government should provide additional funding to the Court to increase the capacity of the court to implement this list. Additionally, funding should be provided to VALS to ensure adequate resources to effectively represent our clients in monthly call-over lists.