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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
39
Protocol with Aboriginal legal and health services for all deaths
That in developing a protocol with Aboriginal Legal Services and Aboriginal Health Services as proposed in Recommendation 38, the State Coroner might consider whether it is appropriate to extend the terms of the protocol to deal with any and all cases of Aboriginal deaths notified to the Coroner and not just to those deaths which occur in custody.
Aboriginal Justice Caucus Assessment
The intent of Recommendation 39 was for the autopsy protocol developed between the State Coroner and Aboriginal services (in response to Recommendation 38) to be applied whenever an Aboriginal passing was investigated by a coroner.
While protocols specific to autopsy have not been developed in Victoria, other actions have been taken with the aim of enhancing the cultural sensitivity of a range of practices that are part of the investigation of Aboriginal deaths in custody. These include:
- Establishment of the Coroners Court Yirramboi Murrup Unit in 2019 ensure that Aboriginal families are supported throughout the coronial process, and court practices respect and respond to cultural protocols.
- Practice Direction 6 which reinforced the importance of culturally sensitive protocols for coronial inquiries into Aboriginal deaths in custody
- Inclusion of a new principle in the Victorian Institute of Forensic Medicine Act 2024 (Vic) to help protect and respect Aboriginal cultural rights. It says that when someone is doing their job or making decisions under this Act, they should consider and respect the cultural beliefs of the people involved—especially when those people are from Aboriginal communities.
- Creation of the Aboriginal Medico-Legal Liaison Officer (AMLO) who is the central point for communication with all Aboriginal families while the person who has passed is in the care of the Victorian Institute of Forensic Medicine. They work closely with the Yirramboi Murrup Unit to support families.
Caucus members, including those referred to in this recommendation, felt that it wasn’t necessary to develop a specific protocol for autopsy, provided the cultural needs of Aboriginal families could be met. This could occur through changes to Practice Direction 6, and greater emphasis on its broader application to all reportable deaths investigated by coroners.
The practical needs of Aboriginal families must also be met.
It’s the least that we can do to ensure that families are supported; that should also include the financial burden of somebody passing in custody. To me it seems that there should be a level of responsibility to the department to wear some of the cost. It's a big ask of the families.
(Nicola Perry-Peters, VACCHO)
Priority for Further Work:
Moderate
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
Extend Practice Direction 6 to apply to other reportable deaths
Extend Practice Direction 6, and the cultural requirements within it, to other contexts where Aboriginal people pass and a coroner is investigating those passings, i.e. Aboriginal children or young people who pass in care, and any other reportable deaths.
Immediate financial support for family after a death in custody
Provide families with a financial support payment to cover funeral expenses, travel, counselling and other assistance required immediately after a person has died in custody (like payments made to families when a child passes in the care of the State). Agencies with custodial responsibilities must contribute to this fund.
Background
The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) emphasised the need for culturally sensitive handling of Aboriginal deaths in custody. Recommendation 38 highlighted the importance of developing protocols in consultation with Aboriginal legal services and Aboriginal health services to guide coronial investigations, autopsies, and the return of the deceased's body with the aim of minimising obstacles to performing traditional rites and sparing families additional grief. The Commission recommended the State Coroner consider extending any protocol to cover all Aboriginal deaths reported to them, not just those that occurred in custody. This protocol was to guide coroners in obtaining advice from the deceased's family and community and ensure cultural and emotional sensitivities are respected.
Actions Taken Since Last Review
Burra Lotjpa Dunguludja
One of the goals of Burra Lotjpa Dunguludja – the fourth phase of the Victorian Aboriginal Justice Agreement (AJA4) is that the needs of Aboriginal people are met through a more culturally informed and safe system. Contributing to this goal are actions to enhance the responsiveness of the Coroners Court to Aboriginal families.
Coroners Court of Victoria
The Yirrumboi Murrup Unit (formerly the Koori Engagement Unit) within the Coroners Court of Victoria was established in 2019 to better meet the needs of Aboriginal families. It aims to increase cultural safety in the Coroners Court, facilitate cultural protocols and support Sorry Business for Aboriginal families, by ensuring that:
- Every Aboriginal passing is recorded, and every Aboriginal family is engaged with
- Court practices reflect cultural protocols and guidelines
- Families are supported through coronial processes in a culturally responsive way.
In 2020, the State Coroner issued Practice Direction 6 – Indigenous Deaths in Custody (Practice Direction 6). This direction highlights the importance of protocols for conducting coronial inquiries into Aboriginal deaths in custody to ensure they are handled in a culturally sensitive and appropriate manner.
With the Koori Engagement Unit, the Coroners Court conducted a review of all cases where Aboriginal passings were notified to the Coroner. They created a projected lifecycle for cases to better assist families and outcomes across all types of reportable deaths.
In 2022, a Women’s Family Engagement Officer was recruited to the Koori Engagement Unit and an Aboriginal Court Administrative Officer also commenced. This increased the support available to Aboriginal men and women impacted by coronial processes in relation to all types of passings reported to the Coroner - those that were unexpected, occurred in custody or care or were the result of suicide.
The Yirramboi Murrup Unit liaises with families on cultural matters and considerations to ensure appropriate arrangements are made throughout the coronial process.
Victorian Institute of Forensic Medicine
The Aboriginal Medico-Legal Liaison Officer (AMLO) is the central point for communication with all Aboriginal families while the person who has passed is in the care of the Victorian Institute of Forensic Medicine (VIFM). The AMLO works closely with the Yirramboi Murrup Unit to ensure consistent messaging and ongoing support is provided to families.
The AMLO is responsible for gathering information from Aboriginal families. This includes concerns of care or concerns that the family would like recorded or investigated by the Coroner. If the concerns are of a medical nature, a nurse from the Coronial Admissions and Enquiries team will call the family to collect information.
The AMLO is involved in liaising with Aboriginal families about the type of medical examination to be conducted. An order is made by the coroner to conduct an autopsy, taking into account the wishes of the family.
Impact
Outputs
The Coroners Act 2008 (Vic), Victorian Institute of Forensic Medicine Act 2024 (Vic) and Practice Direction 6. Establishment of the Yirramboi Murrup Unit within the Coroners Court and an increase in Aboriginal staff, including the Aboriginal Medico-Legal Liaison Officer role within the Victorian Institute of Forensic Medicine.
Outcomes
Recommendation 39 aimed to extend protocols for engaging with Aboriginal families about postmortem examinations all deaths reported to the Coroner rather than only those that occurred in custody. These protocols were to be developed in consultation with Aboriginal legal and health services to ensure cultural sensitivity.
While protocols specific to autopsy have not been developed in Victoria, the State Coroner issued Practice Direction with the aim of enhancing cultural sensitivity around a broad range of practices relevant to the investigation of Aboriginal deaths in custody. It includes:
- Contacting the Victorian Aboriginal Legal Service (VALS) to provide early advice and support to families.
- Consulting families on autopsies and the release of the body of their loved one
- Keeping families informed of delays in medical examination reports.
- Providing culturally sensitive viewings of the deceased.