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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
25
Family have right to view body and scene of death
That unless the State Coroner, or the coroner appointed to conduct the inquiry, directs otherwise, and in writing, the family of the deceased or their representative should have a right to view the body, to view the scene of death, to have an independent observer at any post-mortem that is authorised to be conducted by the Coroner, to engage an independent medical practitioner to be present at the post-mortem or to conduct a further post-mortem, and to receive a copy of the post-mortem report. If the Coroner directs otherwise, a copy of the direction should be sent to the family and to the Aboriginal Legal Service.
While the preparation and service of coronial briefs has been particularly problematic, further delays result from the delinquent completion or provision of autopsy reports and other medical reports.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 25 was to ensure families of those who have passed in custody, are able to view the body, access the scene of death, have an independent observer at autopsy, engage an independent medical practitioner, and receive a copy of the autopsy report.
Actions taken partially align with this recommendation’s intent. The Coroners Act 2008 (Vic) supports the involvement of families in the coronial process, which includes decisions about viewing and releasing the body conducting autopsies, and requesting post-mortem report. Principles in the Victorian Institute of Forensic Medicine Act 2024 (Vic) and Practice Direction 6 aim to improve cultural sensitivity in practice, as evidenced in arrangements made with families to view the body of their loved one.
Prior to a viewing, the Aboriginal Medico-Legal Liaison Officer (AMLO) within the Coronial Admissions and Enquiries team contacts the family to explain the steps in the process. This includes seeking advice as to whether they would like a possum and/or kangaroo skin cloak placed on the person who has passed at the time of the viewing. The AMLO and/or a member of the Yirramboi Murrup Unit will be present at all viewings of an Aboriginal person who has passed, or where a family member identifies as Aboriginal, if requested.
There is limited evidence on the extent to which other elements of Recommendation 25 are implemented. Existing laws do not explicitly provide families the right to have an independent observer during post-mortems, involve an independent medical practitioner, or arrange additional post-mortems. There aren’t any practice directions or commissioner’s requirements to support coroners or custodial authorities to respond to requests from families or their representatives to view the scene of their loved one’s passing.
Further action is needed to implement this recommendation, including informing Aboriginal families of their rights and supporting them to bring their loved one home and journey through sadness to healing.
If we've still got people dying in custody, and we can't provide them the care that they need to not pass in custody, that the least the state can do is ensure that the families on the outside have got the right apparatuses for healing and moving forward.
(Ebony Hickey, Chairperson, Barwon South West RAJAC)
Priority for Further Work:
High
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
Inform Aboriginal families of their rights in coronial processes
Ensure Aboriginal families are informed of their rights in relation to coronial processes, including the right to inspect the scene, have an independent observer at a post-mortem, engage an independent medical practitioner, or conduct a further post-mortem.
Ensure Aboriginal families are supported
Support Aboriginal cultural practices for healing and moving forward (this will differ between families and regions but could include facilitating smoking ceremonies in corrections/police cells, in-community activities, grief counselling, restorative approaches etc).
As outlined in response to Recommendation 24:
Enable families or their legal representatives to inspect the scene of death
Introduce explicit legal provisions for families or their legal representative to inspect the scene of death.
Coroners Court, Corrections Victoria and Victoria Police to update their respective directives and procedures to assist with facilitating family requests to inspect the scene of death.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) emphasised that the family of the deceased or their representative should have the right to view the body, access the scene of death, and have an independent observer present during post-mortem procedures. Cases investigated by the Commission highlighted the distress caused when bodies were swiftly removed for autopsy without allowing the family an opportunity to view them, creating suspicion and uncertainty. Additionally, cultural considerations and concerns relating to autopsies within various Aboriginal communities were outlined. The RCIADIC emphasised the need for timely and explicit communication with bereaved families and relevant Aboriginal organisations, given the importance of their understanding of, and participation in coronial processes.
Actions Taken Since Last Review
Victorian Institute of Forensic Medicine
The objectives of the Victorian Institute of Forensic Medicine (VIFM) include overseeing and coordinating the provision of forensic services in Victoria, assisting the Coroners Court with its functions under the Coroners Act 2008, contributing to public health and safety, the administration of justice and reducing the number of preventable deaths, and contributing to the development of knowledge, practice and innovation in the provision of forensic services.
The new Victorian Institute of Forensic Medicine Act 2024 (Vic) promotes Aboriginal cultural rights by providing that in performing a function or exercising a power, a person should have regard, as far as possible in the circumstances, to respecting the cultural beliefs of persons affected by the events to which the Institute’s services relate, and to recognising the diverse needs of Aboriginal communities, including the importance of self-determination and connection to culture, family, community and Country.
This 24-hour Coronial Admissions and Enquiries service is the first point of contact with the coronial system for families of a deceased person. It has been provided by the VIFM since 2013, when the function was transferred from the Coroners Court.
Nursing and administrative staff within Coronial Admissions and Enquiries assist in the earliest stages of the death investigation. Staff work closely with families providing them with information and support throughout the initial investigation, particularly for those families who need to attend the VIFM to view the body of their family member for identification and therapeutic purposes.
When an Aboriginal passing in custody is reported, the State Coroner is immediately notified as is the Aboriginal Medico-Legal Liaison Officer (AMLO) within the Coronial Admissions and Enquiries team and the Yirramboi Murrup Unit (formerly the Coroners Koori Engagement Unit).
The AMLO will be the central point for communication with all Aboriginal families while the person who has passed is in the care of the VIFM. The AMLO works closely with the Yirramboi Murrup Unit to ensure consistent messaging and ongoing continuous support for families. If the AMLO is not available and another staff member must step in to communicate with the family of an Aboriginal person who has passed, they seek to acknowledge cultural practices and give families a choice in the way in which information is communicated. All Coronial Admissions and Enquiries staff receive mandatory Aboriginal Cultural Awareness Training.
Prior to a viewing, the AMLO contacts the family to explain the steps in the process. This includes seeking advice as to whether they would like a possum and/or kangaroo skin cloak placed on the person who has passed at the time of the viewing. The AMLO and/or a member of the Yirramboi Murrup Unit will be present at all viewings of an Aboriginal person who has passed, or where a family member identifies as Aboriginal, if requested. Extended families are often present. This can include Elders and children. Each family is different; the family is given a choice as to whether they would like to view the deceased through glass or be present in the room with the deceased.
Coroners Court of Victoria
The Coroners Act 2008 (Vic) sets out provisions for investigating reportable deaths, including the release of the deceased's body, the request and conduct of autopsies, and the process for raising objections to autopsies. While these elements are well defined, the Act does not specifically address matters such as viewing the scene of death, the presence of independent observers or medical practitioners at a post-mortem, or the right to request a further post-mortem, as raised in Recommendation 25.
These areas are generally informed by the overarching principles of the Act and further guided by practice directions issued by the State Coroner. In 2020, the State Coroner issued Practice Direction 6, which outlines procedures for investigating Aboriginal deaths in custody. The directive seeks to improve cultural sensitivity in coronial investigations and provides guidance for family involvement, including options to view the body at a funeral home or at the VIFM. It also addresses the facilitation of documentation and court proceedings in a culturally appropriate manner.
Corrections Victoria
In their response, Corrections Victoria noted that the coroner makes determination about who can view the body of the deceased. The scene of a passing at a prison is a crime scene and viewing of the body must occur with the express permission of Victoria Police and the Coroner.
When an Aboriginal person passes in custody, Corrections Victoria provide support to the person’s family (if the family wishes and accepts assistance) through the Naalamba Ganbu and Nerrlinggu Yilam (the Yilam) unit which is made up of Aboriginal staff. Support for staff and people at the facility is also provided and any culturally significant practices required such as a Smoking Ceremony would be arranged by the Yilam.
Impact
Outputs
The Coroners Act 2008 (Vic) provides mechanisms for involving families in the coronial process, including decisions about the release of the body, and conduct of autopsies It also allows the senior next of kin to request access to investigation documents, including post-mortem reports. However, the Coroners Act 2008 does not explicitly grant families the right to view the scene of death, have an independent observer at a post-mortem, or request a second post-mortem. These areas are instead guided by legislative principles and Practice Direction 6, which aims to improve cultural sensitivity in investigations of Aboriginal deaths in custody.
Outcomes
There has been some progress toward addressing Recommendation 25, although key elements are yet to be implemented. The Coroners Act 2008 (Vic) sets out procedures for investigating deaths and conducting autopsies but does not explicitly cover family access to the death scene, independent observers at post-mortems, or further post-mortems, as outlined in Recommendation 25. These areas are guided by legislative principles in the Victorian Institute of Forensic Medicine Act 2024 (Vic) and the State Coroner’s practice directions.
According to VALS, independent medical involvement during post-mortems is uncommon, but families often request independent forensic reviews or expert medical advice as part of the inquest process.
Community Views
Victorian Aboriginal Legal Service
Lawyers within VALS’ Wirraway team were not aware of any instances where families had requested an independent observer be present at a post-mortem but believed that families should be informed of this option by the Coroners Court. They also noted that some families may want cultural rituals, such as smoking ceremonies, performed at the scene of death even if they are unable to access the scene. For many families, the priority is to bring their loved one home as soon as possible.
Previously, VALS’ legal practitioners highlighted delays with the provision of autopsy and other medical reports:
While the preparation and service of coronial briefs has been particularly problematic, further delays result from the delinquent completion or provision of autopsy reports and other medical reports.
Unnecessarily lengthy coronial investigations may exacerbate the distress of families and others affected by a person’s passing. Drawn out proceedings are counter to the aims of the Coroners Act 2008 for the coronial system to operate in a fair and efficient manner.