Through the ARTS structure, recommendations are tabled and accounted for at the CE level. It would require changes to the Coroners Act 2003 (SA) to enforce agencies to formally respond to recommendations (as in Victoria and NSW). This mechanism could improve accountability and transparency for the public regarding the progress (or not) of any recommendations.
Any public statutory authority or entity directed a recommendation must respond in writing within three calendar months about what action has or will be taken. This response, as well as the coroners’ finding, must be published on the CCOV’s website. There are varying views about the adequacy of this process. On the one hand there is the view that this process is adequate because it affords the public statutory authority or entity the necessary discretion to make changes and given the exchange is on the public record, a level of accountability is implied. On the other hand, there is the view that the CCOV should be monitoring the implementation of recommendations. This is beyond the current mandate of the CCOV and the implementation of previous recommendations are often followed up when a subsequent similar death occurs. In this way, there is an ad hoc monitoring function.
| QUESTION | NSW | QLD | | WA CORONER | SA | VIC |
1.16What is the process to monitor, track and review government and agency responses to findings and recommendations? Is it adequate? | The Team monitors recommendations, responses and implementation in its Annual report. This is adequate. | Government agencies are required to report on coronial recommendations annually to the Department of Justice and Attorney General and a report is tabled in the Parliament by the Attorney-General – this is an administrative arrangement only. Progress on the implementation of the DFVDRAB recommendations will be reported annually to the Minister in an Annual Report. | Recommendations arising from the Ombudsman’s reviews and investigations are monitored by the Ombudsman to ensure their implementation and effectiveness. This monitoring includes requesting relevant State Government departments and authorities to provide detailed information regarding the implementation and effectiveness of findings, the response to recommendations and the provision of evidence to support this information, and the Ombudsman analysing and assessing this information. The results of this monitoring are periodically reported to Parliament. | The responses are voluntary. The system is monitored by the State Coroner and responses appear on the website, next to the relevant finding. | The Governance structure of the ARTS agenda enables recommendations to be discussed, actioned and tracked at an Executive level. | See response to 1.14. |
QUESTION | NSW | QLD | WA OMBUDSMAN | WA CORONER | SA | VIC |
1.17Is there evidence that your findings and recommendations are leading to improvements in systems and services aimed at preventing domestic and family violence deaths? How do you assess your progress? | The Team’s recommendations are developed following in-depth multiagency review and additional consultation where necessary and in many cases implemented by the agencies targeted. More detail regarding this can be seen in the Team’s 12/13 and 13/15 (forthcoming) reports.
The Team continues to monitor the implementation of recommendations. Evaluating whether the implemented recommendations are ‘leading to improvements’ to systems and services is not within the ambit of the Team’s work.
| Yes. Coronial recommendations stemming from domestic and family violence related deaths have been adopted and implemented by agencies. This is particularly salient for the Inquest into the death of Noelene Beutel with relevant recommendations being supported in the Special Taskforce Report on Domestic and Family Violence. The Queensland Government has agreed to implement those recommendations, including those relating to the development of a common risk assessment framework and information sharing protocols. | Since the family and domestic violence fatality review jurisdiction commenced on 1 July 2012, the Ombudsman has identified and reported in the annual report on issues relating to the involvement of State Government departments and authorities in relation to family and domestic violence fatalities. In the Annual Report 201415, the Ombudsman also reported on improvements to public administration through the actions undertaken by public authorities to address the identified issues.
In addition to reviews of individual family and domestic violence fatalities and own motion investigations, the Office uses a range of other mechanisms to improve public administration with a view to preventing or reducing family and domestic violence fatalities. These include:
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Assisting public authorities by providing information about issues that have arisen from family and domestic violence fatality reviews, and enquiries and complaints received, that may need their immediate attention, including issues relating to the safety of other parties;
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Through the Ombudsman’s Advisory Panel, and other mechanisms, working with public authorities and communities where individuals may be at risk of family and domestic violence to consider safety issues and potential areas for improvement, and to highlight the critical importance of effective liaison and communication between and within public authorities and communities;
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Exchanging information, where appropriate, with other accountability and oversight agencies including Ombudsmen and family and domestic violence fatality review bodies in other States to facilitate consistent approaches and shared learning;
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Undertaking or supporting research that may provide an opportunity to identify good practices that may assist in the prevention or reduction of family and domestic violence fatalities; and
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