Contents Part executive Summary 8

Challenges, strengths and limitations of Australian death review

The following analysis of death review is from the responses of Australian Coroners and the Western Australian Ombudsman to the Commission’s 2015 Questionnaire. It sets out the strengths and challenges of the death review processes as experienced in each jurisdiction. The full responses to the Commission’s questionnaire are available at Appendix B of this report.

1. Statutory basis

Many Death Review Teams were established by statute.¹⁷⁷ In Australia, the Death Review Team in New South Wales was established by statutory amendments to the Coroners Act 2009 (NSW) in 2009 and the Queensland Death Review Team, was established in 2011 by way of amendment to the Coroners Act 2003 (QLD). These amendments enshrine provisions regarding relevant definitions, the functions of the Teams, their membership and their ability to access information.¹⁷⁸

In South Australia and Victoria, Death Review Teams sit within the Coronial function and operate under existing Coronial legislation. In Western Australia the Team operates in accordance with the Parliamentary Commissioner Act 1971(WA).

The Western Australian Ombudsman, and the South Australian Senior Research Officer (Domestic Violence), have stated that an explicit statutory basis is not necessary as the existing arrangements are sufficient for their work.¹⁷⁹

The New South Wales Coroner submits that a strong statutory basis is a critical element because it empowers and supports the Team to effectively undertake their various functions.¹⁸⁰

The Victorian Coroner and Death Review Team similarly argue that an explicit statutory basis is desirable as it ensures the sustainability of the Review function.¹⁸¹

While a statutory basis may be desirable, it is not the only model for death review. It should not preclude the establishment of new Death Review Teams. In some instances, the process for developing the death review function may be staged.

2. Resourcing

Levels of staffing and other resourcing for Death Review Teams vary across jurisdictions. Most Teams consist of a secretariat of one to two people and are supported by the work of a multidisciplinary team.

In terms of funding, the New South Wales Domestic Violence Death Review team has $500,000 annual funding. This supports the work of the secretariat and broader team. The New South Wales team reports that this is adequate.

The Western Australian Ombudsman undertakes death reviews, and similarly described existing resources as adequate and appropriate.

Other Review Teams reported that improved resourcing levels could improve their work. For example, while the Victorian Systemic Review into Domestic Violence Deaths has stated that current funding levels (which provide for a part-time manager, full-time project officer and the support three other part-time staff members) are sufficient for conducting case-by-case investigations, it indicated that additional resources for research and evaluation would be valuable.

Similarly, the Senior Research Officer (Domestic Violence) in South Australia reported that an additional staff member could enhance the work of the team.¹⁸² The Senior Research Officer also noted that having a broader team that could review the data would also be beneficial.¹⁸³

3. Cases reviewed

1. Open coronial and criminal cases

The majority of Death Review Teams in Australia review both open and closed coronial cases. Teams may also offer advice and support to Coroners in relation to specific open cases.¹⁸⁴

The majority of Teams in Australia do not consider cases while they are subject to criminal proceedings. Many Teams felt that this was the correct approach, for two reasons.

First, some Teams felt that the consideration of open criminal cases could undermine the criminal justice process.¹⁸⁵

Second, Teams noted that waiting until the criminal justice process had been concluded enables them to access a wider range of valuable information for their review, including prosecution materials and sentencing remarks.¹⁸⁶

In contrast, the Western Australian Ombudsman and the Queensland Domestic and Family Violence Death Review and Advisory Board can review cases concurrently with criminal proceedings. The Western Australian Ombudsman has stated that this helps to ensure that death reviews are conducted, and recommendations formulated, in the ‘most timely way possible’.¹⁸⁷

(vii)Non-homicide cases

The focus of most of the work of Domestic and Family Violence Death Review Teams is on cases of domestic violence homicide and homicide-suicide.

However, most Teams in Australia can analyse non-homicide cases. In particular, suicide deaths that occur in a context of domestic and family violence fall within the remit of reviewable deaths by most Death Review Teams.

Death Review Teams have indicated that the analysis of such deaths would be useful.¹⁸⁸ For example, the South Australian Coroner stated that ‘the review of suicide…deaths is valuable in terms of understanding the dynamic that domestic violence may play in those deaths and subsequently informing prevention strategies’.¹⁸⁹ It may therefore be beneficial for Teams to be provided with the support or resources necessary to undertake these reviews.

In jurisdictions with higher numbers of homicide cases, it may be appropriate to prioritise the analysis of homicide cases. However, in smaller jurisdictions, enabling Domestic and Family Violence Death Review Teams to consider non-homicide cases that occur within a context of domestic and family violence may provide the opportunity for Teams to better identify trends and commonalities than would be possible if only homicide cases were considered.¹⁹⁰

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