annual report 2011–12 - department of justice and...

Annual Report 2011–12

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Coronial Council of Victoria Annual Report 2011–12

Contents PageContents Page

Letter to the Attorney-General of Victoria 3

Message from the Chairperson 4

Coronial Council of Victoria 5

Council Members 6

Year in Review 9

The Year Ahead 11

Summary of Financial Expenditure for the 2011–12 Year 12

Appendix 1 13

Coronial Council of Victoria Annual Report 2011–12 3

Letter to the Attorney-General of VictoriaLetter to the Attorney-General of Victoria

The Honourable Robert Clark MP Attorney-General 121 Exhibition Street MELBOURNE VIC 3000

15 August 2012

Dear Attorney-General

On behalf of the Coronial Council of Victoria, I present to you the Annual Report of the Coronial Council of Victoria for the period of 1 July 2011 to 30 June 2012, in accordance with section 113 of the Coroners Act 2008.

The report was prepared under my chairmanship and approved by the Coronial Council of Victoria on 6 August 2012.

Yours sincerely,

James T Duggan Judge of the County Court Chairperson Coronial Council of Victoria

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Message from the ChairpersonMessage from the Chairperson

I am pleased to report that this year has presented the Coronial Council of Victoria with opportunities to develop and meet new challenges.

While expected on its establishment to meet three to four times per year, the Council found it necessary to meet on nine occasions during the 2011–12 financial year.

The Council received two references from the Attorney-General during that financial year. The former was a request to examine measures that might be adopted to assist those affected by coronial investigations in the course of their employment. The Council produced a final report to the Attorney-General on this reference in October 2011. The latter reference was a request to advise whether asbestos-related deaths should be investigated by the coronial jurisdiction. The Council provided a response to this reference in January 2012.

In May 2012 the Attorney-General agreed to make a formal reference to the Council to provide advice on suicide reporting and the coronial jurisdiction, and the Council has begun work on the reference. The Council considers itself well-placed to consider the complex and sensitive issues around suicide reporting and, as the Council is the only body of its kind in Australia, it can take a leading role in coronial reform matters.

The Council also considered other issues, including the development of its website, access to legal representation for families in the coronial system and the difficulties associated with funding pressures placed on the Coroners Court.

In closing, I extend my thanks to Ms Judy Leitch, CEO of the Coroners Court, for providing regular updates to the Council in relation to issues affecting the Court, and to the Council’s secretariat (staffed in turn by Ms Lisa Nicholas and Ms Erica Capuzza) for providing support throughout the past year.

Finally, I thank the members of the Council for their continued enthusiasm and hard work, and for their energetic dedication to embracing the extra responsibilities of the Council in addition to their demanding work schedules.

I am delighted to present the 2011–12 annual report.

James T Duggan Judge of the County Court Chairperson Coronial Council of Victoria


Coronial Council of VictoriaCoronial Council of Victoria

The Coronial Council is the first of its kind in Australia and is designed to be sufficiently flexible to deal with the complexities of the jurisdiction. The Council is expected to act in a way that:

• does not impinge on the independence of a coroner’s decision-making and investigation of death as well as the role of the State Coroner;

• delivers strategic advice reflecting the changing physical, social and political environment to foster a modern and responsive coronial system;

• promotes and strengthens different relationships including collaboration between agencies across the coronial system;

• focuses on advice to strengthen services to families and improve the prevention role of the coroner;

• ensures that the views of bereaved families are reflected in the development of advice;

• complements existing governance structures in the State coronial system; and

• promotes transparency, accessibility and accountability regarding the functions of the Victorian coronial system.

1 Refer to Appendix 1.

The Coronial Council was developed as part of the Victorian Government’s broad reform strategy following the release of the Victorian Parliament Law Reform Committee’s Final Report on the Coroners Act 1985 (the VPLRC Report) in September 2006. This reform strategy was designed to develop an integrated governance, legislation and service delivery framework to support a modern and responsive coronial system. Since the VPLRC Report, there has been significant reform to the coronial system, including the introduction of the Coroners Act 2008 (the Act) which came in to operation on 1 November 2009.

The Coronial Council of Victoria was established under section 109 of the Act1. The Council is independent of the Coroners Court and provides advice and recommendations to the Attorney-General regarding matters of importance to the coronial system in Victoria. These may include:

• the identification of themes, trends and patterns that are seen to emerge;

• legislative issues; and

• proposed law reform.

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Council MembersCouncil Members

Membership of the Council is set out in section 111 of the Coroners Act. The Council consists of three statutory members and seven non-statutory members appointed by the Governor-in-Council on recommendation by the Attorney-General. Members are appointed for up to three years and are eligible for re-appointment.

Statutory members:• State Coroner Judge Jennifer Coate

• Victorian Institute of Forensic Medicine Director Professor Stephen Cordner

• Victoria Police Chief Commissioner (represented on the Council by Deputy Commissioner Graham Ashton).

Non-statutory members of the Council were chosen on the basis of merit and for the diversity of experience they bring to the role. This includes an understanding of the issues that affect the coronial jurisdiction, as well as other aspects that intersect with the coronial jurisdiction. Members are appointed for up to three years and are eligible for re-appointment.

Non-statutory members:• Judge James Duggan (Chairperson)

• Mr Stephen Dimopoulos

• Dr Ian Freckelton SC

• Mr Chris Hall

• Professor Katherine McGrath

• Dr Sally Wilkins

• Dr Rob Roseby.

The Council is supported by a Secretariat, provided by the Department of Justice.

Council members 2012

Back (L to R): Mr Stephen Dimopoulos; Dr Ian Freckelton SC; Judge James Duggan (Chair). Front (L to R): Judge Jennifer Coate, Dr Sally Wilkins, Professor Katherine McGrath. Absent: Professor Stephen Cordner; Deputy Commissioner Graham Ashton; Mr Christopher Hall; Dr Rob Roseby. Photograph by Janti Lakusa.


Judge James Duggan

His Honour Judge James Duggan was appointed chairperson of the Coronial Council of Victoria on 23 February 2010. Judge Duggan has been a judge of the County Court of Victoria since 1984 and, upon retirement in 2008, was appointed an Acting Judge.

Judge Jennifer Coate, State CoronerHer Honour Judge Jennifer Coate was appointed State Coroner of Victoria in November 2007, having previously been appointed a Judge of the County Court and the inaugural President of the Children’s Court of Victoria in 2000.

Professor Stephen Cordner, Director of the Victorian Institute of Forensic Medicine Professor Stephen Cordner was appointed Foundation Professor of Forensic Medicine at Monash University and Foundation Director of the Victorian Institute of Forensic Medicine (VIFM) in 1987. He was awarded Member of the Order of Australia (AM) for services to forensic medicine in January 2005.

During this reporting year, VIFM was also represented on the Council by Deputy Director, Associate Professor David Ranson.

Chief Commissioner of PoliceIn 2011–12, the Chief Commissioner of Police, Mr Ken Lay, was represented on the Council by Deputy Commissioner Graham Ashton. A former Australian Federal Police officer, D/C Ashton was tasked with Operational Command of the Australian law enforcement response to the Bali bombings, for which he was awarded Member of the Order of Australia (AM) in October 2003. In addition to his counter-terrorism experience, D/C Ashton also worked with the Victorian Office of Police Integrity. He joined Victoria Police in December 2009 and was appointed Deputy Commissioner in early 2012.

Mr Stephen Dimopoulos Mr Stephen Dimopoulos is employed within the Victorian public service and is currently serving as a Councillor for Monash City Council. He has significant experience in working with Victoria’s culturally and linguistically diverse communities including through his role with Monash Council and his previous membership of the boards of community organisations that provide services for and advocate on behalf of Victoria’s culturally and linguistically diverse communities. These include the Southern Ethnic Advice and Advocacy Service and the South Central Region Migrant Resource Centre. Mr Dimopoulos is currently Chairperson of the Monash Multicultural Advisory Committee.

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Dr Ian Freckelton SCDr Ian Freckelton is a Senior Counsel in full-time practice at the Victorian Bar and a Professor in the Faculty of Law and the Departments of Psychological Medicine and Forensic Medicine at Monash University. He is the author of many books, including Death Investigation and the Coroner’s Inquest (co-authored with Associate Professor David Ranson) and is editor of the Journal of Law and Medicine.

Mr Christopher HallMr Chris Hall is the Director of the Australian Centre for Grief and Bereavement, a position he has held for the past 14 years. The Australian Centre for Grief and Bereavement is the largest provider of grief and bereavement education and clinical programs in Australia.

Professor Katherine McGrathProfessor Katherine McGrath is a widely respected health care executive with over 30 years experience in government, public health, private health, clinical and academic posts. Her roles have included Deputy Director General of NSW Health and Chief Executive Officer of Hunter Area Health Service.

Dr Rob Roseby Dr Rob Roseby is a Respiratory and General paediatrician and Head of Medical Education at Monash Children’s at Southern Health. He was a paediatrician at the Royal Children’s Hospital, and Deputy Director of Adolescent Medicine and Head of Paediatrics at Alice Springs Hospital for six years to mid-2009, and now has significant involvement with the Royal Australasian College of Physicians.

Dr Sally WilkinsDr Sally Wilkins is a consultant psychiatrist and has worked in the Victorian mental health sector for 30 years. From 2002 until 2009, she was Head of Community Psychiatry at The Alfred Hospital where she was responsible for major reform of all the community-based psychiatric programs.


Year in ReviewYear in Review

The 2011–12 year was a successful and productive one for the Coronial Council. It was intended that the Council would meet three to four times each year, however the Council held nine meetings during the year due to an increasing workload.

The Council’s statutory function is to provide advice and recommendations to the Attorney-General on matters connected with and oversight of the Victorian coronial system. The advice can be provided either at the request of the Attorney-General or of the Council’s own motion.

The first referenceIn July 2010, the former Attorney-General, the Hon Rob Hulls MP, provided the Council with its first reference under section 110 of the Act on measures that could be adopted to assist those affected by coronial investigations in the course of their employment. It was recognised that individuals coming into contact with the coronial system in the course of their employment could also be impacted by their experiences, particularly employees and employers who participate in inquests. The reference provided an opportunity for the Council to explore potential initiatives which could minimise any negative effects and promote any positive effects of interaction with the coronial process for these individuals.

Response and recommendationsThe Council produced a final report with recommendations to the Attorney-General, the Hon Robert Clark MP, in October 2011.

In June 2012 the Attorney-General responded to the Council, noting the advice and recommendations the Council provided on measures that could be adopted. The Attorney-General also advised the Council that the report would be published with appendices, thereby providing the history and purpose behind why this reference was chosen. The Attorney-General also approved distribution of the report to those consulted as part of this reference, and thanked the Council for the time and professionalism it has given to this reference.

Reference on asbestos related deathsIn June 2011, the Attorney-General made the following reference to the Council:

The Coronial Council is requested to provide advice as to whether asbestos related deaths should be the subject of coronial investigations. The Council is invited to make additional comments, if deemed appropriate, in relation to this issue.

In 2004, the former Victorian State Coroner gave a direction that all deaths caused by asbestos, or where asbestos was a contributing factor, were to be reported to the State Coroner’s Office. Pursuant to that direction, limited investigations into these deaths were undertaken by the State Coroners Office.

Upon commencement of the new coronial legislation in 2009, the current State Coroner Judge Jennifer Coate announced that asbestos related deaths would no longer be investigated by the Coroners Court, as such deaths are not ‘reportable’ within the meaning of the Act.2 The Act allows for certain types of deaths to be investigated by the coronial system, if prescribed by regulation. The Attorney-General has asked the Council to consider whether asbestos related deaths should be prescribed as reportable deaths under section 4(2)(j) of the Act.

2 Asbestos related deaths may be investigated by a coroner if the death is otherwise reportable.

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Response and recommendationsThe Council provided a response to the reference on asbestos related deaths in January 2012 and awaits a response from the Attorney-General to this reference. It is anticipated that the Attorney-General will make this report publicly available shortly.

Suicide reporting referenceSuicide is a leading cause of death for men and women under the age of 34, accounting for more deaths in Australia than transport accidents and homicides combined. Reliable data on suicide are vital for achieving public health objectives and suicide prevention. However, research has shown that suicide rates are underreported in official figures.

The coronial jurisdiction plays a critical role in the process of recording suicide deaths. The relevant state and national bodies rely upon coronial findings regarding causes and circumstances of death when compiling official statistics. There is a strong public interest in coroners reporting findings in a way that allows accurate statistics regarding the incidence of suicide to be collated for public health and safety purposes.

However, coroners do not systematically and consistently make explicit findings that a deceased person committed suicide. Reasons for this include uncertainty regarding the standard of proof to be satisfied under the law, and concern for the bereaved about the impact of delivering a suicide finding. Coronial practices therefore have the potential to contribute to underreporting of suicides in Australia, and in turn to impact upon suicide research and prevention activities.

On 20 December 2011 the Council wrote to the Attorney-General requesting that a reference be provided to the Council in the following terms:

“The Coronial Council is requested to provide advice on:

1) the application of legal principles regarding suicide, including the operation of the presumption against suicide under the common law and consideration of the evidence broadly considered necessary to establish the mental element of suicide;

2) whether a change to the existing law regarding the standard of proof for a finding of suicide is desirable;

3) policy that enables a consistent approach to coronial determination of intent; and

4) the reporting of suicide in the media, including an appropriate position for the Coroners Court to adopt on this issue.

In formulating its advice, the Council may have regard to the interests of families, the Registry of Births Deaths & Marriages, public health bodies, and any other relevant entities.

The Council is also invited to make recommendations or any further comments that it deems appropriate regarding the issue of suicide reporting in the coronial jurisdiction.”

In May 2012 the Attorney-General agreed to make the formal reference to the Council in the above terms, and the Council has begun work on the reference.

The Council looks forward to drawing on the expertise of its membership in exploring ways to improve the quality of suicide data and enhance the preventive function of Victoria’s coroners.


The Year AheadThe Year Ahead

In addition to the issues referred to it by the Attorney-General, matters considered by the Council during the year included:

Funding pressures in Coroners CourtFor many people, contact with the coronial system comes at the most difficult and traumatic time of their lives. It is of prime importance that the Coroners Court be able to deal with these matters in a sensitive and timely manner. The commitment of the Court’s staff, who appreciate the importance of this service, is commendable.

The Coronial Council is concerned that the capacity of the Court to do what it now does so well will be destroyed if funding cuts to the Court being implemented as part of the Sustainable Government Initiative are of any magnitude. This will have serious consequences for the system and the vulnerable people forced into sudden contact with it.

The Council is of the opinion that the backlog of cases is greater than it should be. Proposed staff cuts will make the position much worse. An efficient coronial system has taken a long time to achieve. The damage caused by losing it will be very real to many people.

Legal representation for familiesThe Council is currently considering the issue of the availability of legal representation for families of deceased persons at coronial inquests. Grieving families of deceased persons often find the coronial process intimidating and frustrating. Appropriate legal representation can and does assist in reducing the levels of these problems.

In situations where it is clear that families require legal representation, the Council is considering whether it is appropriate for the Court to recommend that they obtain representation, how that might be achieved and if other avenues of assistance are feasible.

At inquest, other represented parties often have very different interests to the families.

Frequently, those parties have the resources to fund powerful representation. If the only opposing interest is an unrepresented family, the task of the coroner is that much more difficult. This complicates and can extend the coronial process.

WebsiteThe Coronial Council’s web content currently appears on the Coroners Court website. As the entities are completely independent of each other, it is important that this be reflected publically in the Council’s web presence.

The Council is currently undertaking work to have its own website developed and intends to ‘go live’ in the coming months.

Future directionsDuring the course of its meetings during 2011–12, the Council identified a range of additional medico-legal issues of importance to the coronial system in Victoria. These matters may become the focus of the Council’s activities in future years.

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Summary of Financial Expenditure for the 2011–12 Year Summary of Financial Expenditure for the 2011–12 Year

Council meetings and associated costs are met each year by an output appropriation through the Department of Justice. Expenditure includes sitting fees paid in accordance with the Appointment and Remuneration Guidelines for Victorian Government Boards, Statutory Bodies and Advisory Committees (January 2010), meeting costs and incidentals, cab charges, and costs associated with events such as conferences.

Statutory members and members who are also full-time Executive Officers or equivalent in a Victorian public sector position are not remunerated.

The figures below include costs associated with the production of the Coronial Council of Victoria 2010–11Annual Report.

The largest expense is that of the Secretariat. This figure represents a percentage of salary costs for preparation for and attendance at meetings and conferences, undertaking research and performing administrative matters on behalf of the Council.

2011–12 Period

Major Expense Item: Summary of Council Expenditure*

Secretariat costs $37,764.00

Sitting fees $10,053.50

Meeting costs/incidentals $1,388.35

Car/taxi hire $413.09

Conference costs $598.38

Publications/printing $1,060.61

TOTAL $51,277.93

*Expenditure is a composite of actual and allocated costs incurred by the Council from all sources.


Appendix 1Appendix 1

s. 111 Members of the Council

(1) The Council consists of—

(a) the State Coroner;

(b) the Director of the Institute;

(c) the Chief Commissioner of Police; and

(d) five to seven other members appointed by the Governor in Council on the recommendation of the Attorney-General.

(2) A member of the Council appointed under subsection (1)(d)—

(a) holds office for the term, not exceeding three years, that is specified in his or her instrument of appointment;

(b) is eligible for re-appointment; and

(c) may resign from office by delivering a letter of resignation to the Attorney-General; and

(d) is entitled to the remuneration and allowances specified in the instrument of appointment and to be reimbursed for expenses.

(3) The Governor in Council, on the recommendation of the Attorney-General, must appoint a member appointed under subsection (1)(d) to be the Chairperson of the Council.

Part 9—Coronial Council of Victoria

s. 109 Coronial Council of Victoria

The Coronial Council of Victoria is established.

s. 110 Function of the Council

(1) The function of the Council is to provide advice, and make recommendations, to the Attorney-General either—

(a) of its own motion; or

(b) at the request of the Attorney-General.

(2) Advice and recommendations prepared under subsection (1) must be in respect of—

(a) issues of importance to the coronial system in Victoria;

(b) matters relating to the preventative role played by the Coroners Court;

(c) the way in which the coronial system engages with families and respects the cultural diversity of families; and

(d) any other matters relating to the coronial system that are referred to the Council by the Attorney-General.

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s. 112 Procedure at meetings

(1) The Chairperson or, in his or her absence, a member of the Council elected by the members present at a meeting, must preside at a meeting of the Council.

(2) The person presiding at the meeting must ensure that decisions made at the meeting, including any recommendations, are recorded in writing.

(3) Five members constitute a quorum of the Council.

(4) Subject to this section, the Council may otherwise regulate its own procedure.

s. 113 Annual report

(1) As soon as practicable each year but not later than 31 October, the Council must submit to the Attorney-General a report—

(a) of its operations for the year ending on 30 June that year; and

(b) that includes any prescribed matter.

(2) The Attorney-General must cause each annual report submitted to him or her under this section to be presented to each House of Parliament within seven sitting days of that House after receiving it.

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Published by the Victorian Government, Melbourne, Victoria, Australia.

August 2012

© Copyright State of Victoria, 2012 ISSN 1838-3246 (Print)

ISSN 1838-3602 (Online)

This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the

Copyright Act 1968 (Cth).

Authorised by the Coronial Council of Victoria c/- Level 24, 121 Exhibition Street, Melbourne 3000

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