Despite acknowledging before the election that the state coroner “lacks sufficient resources”, the government has so far failed to move on significant reform. Last year a statutory review of the NSW Coroner’s Act recommended an overhaul of the court, and the government says it is reviewing its findings.
While Attorney-General Michael Daley conceded in a recent budget estimates hearing that the court faced “head count” issues, he said major reform to make the court a specialist jurisdiction would be “very expensive”. He recently funded an additional two “behind the scenes” solicitors to help with the caseload, and the government has injected additional funding to carry out an inquest into the Bondi Junction attack.
The backlog has prompted concerns that many preventable deaths may be going unexamined, with the Coroners Court unable to shift its focus to cases that could help prevent people from dying.
“The coroners are up to their ears in mandatory cases, and they are trying to reduce the backlog, but they simply do not have sufficient resources,” former NSW deputy state coroner and University of NSW adjunct professor Hugh Dillon said.
“That means there is less and less room for discretionary inquests, which is important because those are more likely to result in preventive recommendations which can stop deaths occurring. The system is not working as it should be.”
It took a year after Bridgette Porter’s death in 2020 – a shockingly violent case in which her murderer was found guilty but not criminally responsible in 2021 – before the coroner wrote to the family to say an inquest would not be held.
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That changed in 2024, when Keukenmeester wrote to the coroner requesting an inquest to probe into whether signs were missed in the lead-up to her daughter’s murder – including the mental health of the perpetrator – which could have prevented it.
“We felt that if signs had been acted on earlier, then Biddy’s death could have been prevented,” she said.
“That’s what we’d like to have come out, as well as some transparency around the decision-making of certain people.”
The coroner’s workload also means longer wait times for families in cases where an inquest is granted.
Of the 75 relevant coronial findings in 2024, 73 per cent took more than three years from the date of death or suspected death to completion, Dillon said.
Some inquiries and reviews have recommended an overhaul of the Coroners Court. In 2022, a parliamentary select committee, led by former Labor MP Adam Searle, recommended the court be reformed into an “autonomous and specialist” unit separate from the Local Court, and receive an injection of funding to address delays and backlogs.
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I have been dragged through an unreasonably long coronial process now still ongoing for 2 years. The coronial legal team (crown solicitor and assisting counsel) have been referred by the legal services commissioner for misconduct including creating prejudice, misleading lawyers, technical incompetence, misleading witnesses and submitting falsified evidence. The court registrar just stonewalls any attempt to get information. Seems pretty clear the coroner Teresa O’Sullivan was biased and a lot of prejudice and the whole thing was run as a targeting persecuting case and didn’t really even look at most of the issues around the death. What a shame and expensive mess. I’m working with the bar association and law society now who are investigating and seems a lot limit was a pre-determined result and the coroner herself may have participated in the bias. She certainly allowed a lot of misleading statements from the assisting counsel and accepted her “summary” after submissions that was full of bias, reconstructions and falsified witness testimony. She openly accepted it and did not take much time to make her findings and obviously didn’t examine it in much depth and didn’t seem to notice or care that the other layers had not seen it. This whole campaign against me has been a. Relentless attempt to frame me and has cost taxpayers millions.
Great story of NSW govt corruption for an investigative journalist… 2 lawyers and 2 barristers from govt agencies referred for investigation by the office of legal services commissioner, ombudsman investigation. NSW police refusing to investigate misconduct despite witnesses and evidence, civil suits being prepared amidst shocking levels of misconduct and incompetence in efforts to frame events whilst spending millions.