“The real thinkers in this field think of coroners as public health and public safety officials, and even people engaged in human rights,” says former New South Wales deputy coroner Hugh Dillon.

“If you think about it, the basic human right is the right to life, to live safely without being shot by police or killed by corrective services – accidentally or otherwise.”

Around 20,000 deaths a year are reported to coroners, but not all go to inquest. Deaths in custody are mandatorily reported to coroners for investigation, and in each case, it is likely one of the most traumatic moments of their families’ lives, and often made worse by a under-resourced coronial system beset by delays.

And in many cases, the recommendations delivered by coroners to prevent it happening to someone else go unheeded.

This week, Guardian Australia launched its major investigation into Indigenous deaths in custody, examining the continuing high rates 25 years after a royal commission into the issue, and the continuing failures in care by the custodial system.

A common complaint around reviews, royal commission and inquests in Australia is that recommendations are made and then left on a shelf, including those 339 made by the royal commission into deaths in custody.



“A lot of people wouldn’t be deceased if those recommendations had been followed,” human rights lawyer George Newhouse said last year.

“A lot of energy goes into some of these inquests … But then if recommendations aren’t followed up, people will continue to die.”

Human rights lawyer George Newhouse. Photograph: Joel Carrett/AAP

In August 2016 a young man took his own life by hanging in his cell at Darwin’s new prison. In findings handed down in February this year, the coroner, Greg Cavanagh, did not formally recommend the prison address the obvious hanging risks in cells, because he already had, six months earlier after the death of another prisoner: Roy Melbourne.

It was also a specific recommendation – number 165 – of the royal commission.

“It beggars belief that a prison designed and constructed in the 21st century has such classic hanging points with no mitigation of that risk,” Cavanagh said in his Melbourne findings.

Northern Territory correctional services is yet to fix the problem.

In 2010 Cavanagh recommended health screening of people taken into custody by police include the question “do you have an injury” after the death of a man in a Darwin watch house. New processes were established, but failed two years later – the inquest of 27-year-old Kwementyaye Briscoe, who died in the Alice Springs watch house, found he was so intoxicated he was “incapable” of completing the questionnaire.

“In spite of that a box on the form was ticked to suggest Kwementyaye was ‘fit for custody’,” said Cavanagh.

“There is no excuse for such a haphazard, careless attitude to prisoner health.”

We are in a far worse condition than we were 27 years ago Special counsel John Lawrence

Briscoe’s death was also startlingly similar to the death of CT in the Alice Springs watch house two-and-a-half years earlier.

“The deceased should not have died face down in a police cell in circumstances where no risk assessment had been carried out to assess his health or wellbeing.”

John Lawrence, a Darwin-based senior counsel, says the lack of action on recommendations from Indigenous death in custody inquests is a symptom of racism more than logistics or mismanagement.

“Those two case studies [CT and Briscoe] graphically illustrate what can only be explained by racism – direct or indirect – rather than any lack of authority or power in the Coroners Act,” he tells Guardian Australia.

“To watch what happened to both, seen from CCTV, is horrific.”

In 2015 a Warlpiri man, Kumanjayi Langdon, died in police lock-up in Darwin. Langdon had committed no crime and was instead detained under police powers of paperless arrest. Cavanagh recommended the law be repealed, but it remains in place, and has been repeatedly accused of unfairly targeting Indigenous people.

Lawrence says the cases are accumulating and increasing, as are multiple, un-acted upon inquiries into Indigenous justice issues.



“To the extent now, and evidenced by the royal commission into Don Dale and the lack of action there after, the legal system now is unsustainable,” he says.

“We are in a far worse condition than we were 27 years ago when it was described then as appalling. The imprisonment rate is double what it was then. The recommendations haven’t been complied with.

“The people involved in it have lost any idea or direction as to where it’s going, which is out of control.”

The average length of time between death and inquest in the Northern Territory is 1.19 years. Photograph: Jonny Weeks/The Guardian

Guardian Australia’s analysis has detected rising frustrations among several coroners, who would find their recommendations had gone unheeded when another similar death came before them.



The data showed coroners are more likely to make recommendations in death in custody cases when the deceased is Indigenous, that Indigenous deaths were more likely to have an occasion leading up to the death identified by the coroner where proper procedure was not followed – 35% of cases compared with 21% of non-Indigenous cases.

Some jurisdictions, such as Queensland, publish government responses to coronial recommendations, perhaps encouraging more substantive action.

Dillon says studies in New Zealand and Victoria found about 40% of coronial recommendations were acted on, and 30% rejected outright for reasons which included action no longer being necessary.

There is no data available for the rate of action on recommendations in NSW.

Dillon describes NSW as one of Australia’s oldest, least resourced and most dysfunctional coronial systems.

“The local court does not think coronial work should receive a very high priority and it’s clear in the way they allocate the resources,” says Dillon.

NSW’s total expenditure of $6.8m on coronial matters in 2016-17 was also far below what Dillon says are the most comparable states – Victoria and Queensland, which spent $13.2m and $10.7m respectively.

“NSW has had a long-standing practice of doing coronial work on the cheap,” says Dillon, who recommends a total overhaul targeting: the structure of the NSW court, its administration, the selection and training of coroners, the resourcing, and its lack of functional recognition of its death preventative purpose.

Western Australia and Victoria have both completed reviews of their coronial systems in recent years. Queensland completed a review into its system in January, but won’t release the full report. The NSW act is currently under review.

A failing system has a devastating impact on families.

According to Guardian Australia’s analysis of its death in custody database, the average length of time between death and inquest is 2.1 years. The longest average is in South Australia with 3.3 years, followed by WA with 2.8 years. The NT has the shortest at 1.19 years and it’s the only jurisdiction which hears cases within what Dillon describes as the “sweet spot” of 12 to 18 months after a death.

Newhouse shares the same view, but suggests six months to a year is ideal.

Ms Mandijarra died in November 2012, in a Broome police lock-up. The inquest into her death did not begin until February 2016, and wasn’t finalised until March the following year.

The family of David Dungay Jr waited more than two years for an inquest into his death in custody to begin, only to see it fail to be completed within the two weeks set down.

When the deputy coroner Derek Lee informed the family they would have to wait until the following year, Dungay’s nephew Paul Silva stood and yelled: “In a year another black person will be dead.”

Leetona Dungay, the mother of David Dungay Jr, with family and supporters, outside the inquest into her son’s death. Photograph: Carly Earl/The Guardian

Dillon’s view is formed not just by his career as a coroner, but also his own family’s experience with the system when his father passed away and the death, determined to be natural causes, went to a coroner.

“My personal feeling is it takes about a year to go through the grieving process to the point where you feel up to dealing with all the issues in a public forum, you’re ready to kind of face that stuff,” he says.

“I think if you held it about one year to 18 months [after the death], that’s probably the sweet spot. It also gives you time to investigate something pretty thoroughly. That’s enough time for a police investigation, a medical investigation.”

A backlog of cases across Australia has been blamed on a number of issues, including inadequate resources, poor time management by coroners or legal teams during inquests, and increasing reporting of natural deaths.

National benchmarks say no more than 10% of inquest lodgements pending completion should be more than a year old, and none should be more than two years old, according to the Productivity Commission, which did not provide a breakdown of results for coronial matters.

In 2016-17 South Australia had the worst clearance rate for cases, followed by Queensland and NSW, having more cases opened than were finalised. Other jurisdictions cleared as many or more cases as were begun during that time.

Between 2010 and 2015 it took as long as 1,951 days for a death in custody case to reach inquest at a coroner’s court.

Dillon says there are mitigating techniques available to coroners, such as taking greater control over the lines of questioning or applying stopwatches to legal teams, but at the very least families should be better prepared.



“You’ve got to be very frank and you’ve got to explain to them how the system is working,” he says.

“People appreciate the effort, but also the whole thing is about showing them respect.”