2016-02-23
Ms PENNICUIK (Southern Metropolitan) — My adjournment matter is for the Attorney-General. It concerns the need for an independent body to monitor the implementation of responses to coronial recommendations and to track the potential impact on preventable deaths. In 2008 I moved an amendment to the Coroners Bill 2008 which is now part of section 72 of the Coroners Act 2008. It requires a public authority or entity to publicly respond within three months to any recommendations directed to it by the coroner as to any actions it has or will take in respect of the recommendations.
Since section 72 came into operation my office has followed up a large number of the recommendations and responses by agencies, which vary greatly. Sometimes agencies respond promptly, sometimes they do not. I have lodged questions to various ministers on the lack of action to implement certain coronial recommendations. In some cases I was told to look at the department's response on the Coroners Court website, which was of no assistance since my questions concerned the actual implementation not simply the initial written response, which I already had access to.
In addition, research shows that the quality of responses by government departments and agencies to coronial recommendations varies considerably. In a BMC Public Health study of organisations that received recommendations from Victorian coroners over a 33-month period only a third of the recommendations were implemented by the organisations to which they were directed. In December 2015 retiring State Coroner, Ian Gray, said a system should be established to track which recommendations have been implemented since there is little follow-up, if any, beyond organisations providing the initial response within three months.
The Federation of Community Legal Centres has also been advocating for an independent body to be established to follow up implementation of coronial recommendations as outlined in its issues paper of March 2013 entitled Saving lives by joining up justice. This is also recommended in the Queensland Ombudsman report of December 2006 entitled The Coronial Recommendations Project.
Subject to consultation with all relevant stakeholders, possible approaches could be either to establish a new independent body to undertake this function or to provide additional resources to the Victorian Ombudsman to do this and to provide additional resources to the Coroners Prevention Unit (CPU) to monitor those recommendations which fall outside the jurisdiction of the Ombudsman. It is important that such a body or the Ombudsman and, where appropriate, the CPU report publicly on the implementation of responses, particularly to assist families of deceased persons, many of whom who are currently left not knowing if coronial recommendations have ever been implemented. My request of the Attorney-General is that he give serious consideration to the establishment of a body to monitor the implementation of coronial recommendations to public authorities and agencies in Victoria.
Reply: 23 March 2016
The Coroners Act 2008 establishes a modem and effective regime that reduces the number of preventable deaths in Victoria. The coroners' role in contributing to the reduction of preventable deaths is expressly recognised in both the preamble and the objectives provisions of the Coroners Act.
Public authorities and entities are required to respond to coronial recommendations within three months of receiving the recommendations of the coroner. The requirement for the Coroners Court to publish each response on the Internet is unique to Victoria. In this regard, the BMC Public Health study recognised that England and Wales are the only international jurisdictions with mandatory response regimes that resemble Victoria's, although, unlike Victoria, responses in those regimes are not published. The requirement to respond within three months of receiving the recommendations creates transparency and also places pressure on the authority to assess and respond promptly to the recommendations of the coroner.
The Coroners Prevention Unit (CPU) is well established within the Victorian coronial process and has a central goal to increase the uptake and implementation of coronial recommendations. It has an important role in supporting coroners to fulfil their prevention mandate, by assisting coroners to identify opportunities for, and strengthen, public health and safety through the formulation of evidence-based and feasible recommendations. In conjunction with leading public health experts, the CPU also undertakes projects to evaluate the impact of implemented coronial recommendations on preventable deaths in particular areas. This generates a better understanding of preventable deaths in Victoria and enables more effective future intervention opportunities.
Victoria also has oversight mechanisms in relation to public authorities and entities, with broad measures to ensure transparency and accountability of decision-making. The Ombudsman has extensive powers to enquire into or investigate any administrative action taken by, or in, an authority.
For these reasons, I consider that the existing coronial legislative framework in Victoria, in terms of the mandatory response regime, and the oversight mechanisms available in relation to public authorities and entities, provides a comprehensive accountability mechanism to ensure coronial recommendations are appropriately considered.