Inquiry into the Review of the Coroner's Act 1985

Content and news

The Law Reform Committee was given terms of reference for the Inquiry into the Review of the Coroners Act 1985 on 7 December 2004.

The Committee's final report for this Inquiry was tabled in Parliament on 14 September 2006 and is pdf available for download as a PDF file 3.33 Mb. Other documents released by the Commmittee are also available for download from the Reports tab.

Terms of Reference

Referred by the Governor in Council on 7 December 2004.

To inquire into and report to Parliament on the effectiveness of the Coroners Act 1985 (the Act) and to consider whether the Act (excluding Part 9) provides an appropriate legislative framework for:

  1. the independent investigation of deaths and fires in Victoria;
  2. the making of recommendations to:
    1. prevent deaths and fires in Victoria; and
    2. improve the safety of Victorians; and
  3. the provision of support for the families, friends and others associated with a deceased person who is the subject of a coronial inquiry.

In particular, the Committee is required to recommend any areas where the Act should be amended or modernised to better meet the needs of the Community.

In making its inquiry the Committee should examine equivalent legislation and its operation in other jurisdictions.

Hearings and Transcripts

The Committee may invite witnesses to a public hearing, to make representations directly to the members of the Committee and to answer questions put by the Committee. This allows the Committee to follow up points of interest and concern and often lets people who have made a submission amplify points and give additional information.

Public hearings are recorded and a transcript of evidence prepared, to ensure that the Committee has an accurate record of proceedings.

The Law Reform Committee held public hearings for this inquiry in Melbourne on:

Please note:

A number of people spoke to the Committee about their personal experiences as family members involved in a coronial process. Some of these witnesses expressed the opinion that their relative had received inadequate medical treatment before his or her death.

By making the transcripts from the public hearings available on its website in their entirety, the Committee does not endorse or in any way judge the accuracy or otherwise of the opinions expressed. The Committee accepts that some of the medical staff and institutions involved may have a different opinion concerning the standard or level of medical treatment involved in a particular case.

It is important to note that the Committee's inquiry is limited by the terms of reference which direct the Committee to consider an appropriate legislative framework for the Coroners Act. As such in its final report, the Committee cannot investigate individual cases, or make findings about the standard or level of medical treatment in individual cases.

Transcripts of evidence

Melbourne, 22 August 2005

  1. pdf Mr Graeme Bond - pdf 55.91 Kb
    pdf Presentation - pdf 62.31 Kb
  2. pdf Mrs Caroline Storm - pdf 52.64 Kb
  3. pdf Ms Carol Smith - pdf 50.47 Kb
  4. pdf Ms Marion Stevens - pdf 42.17 Kb
  5. pdf Ms Katherine Brand and Dr Maartje Van-der-Vlies, criminologist - pdf 42.75 Kb
  6. pdf Mrs Lynette King and Mrs Anne Anderson - pdf 79.89 Kb
  7. pdf Mr Leon Hain - pdf 59.07 Kb
  8. pdf Mr David Kaufmann, Mrs Margrit Kaufmann, and Mr David Taylor, community development officer, Springvale Monash Legal Centre - pdf 59.93 Kb

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Melbourne, 19 September 2005

  1. pdf State Coroner's Office - pdf 109.09 Kb
    Mr Graeme Johnstone, State Coroner
    Mr Ian West, Deputy State Coroner
    Mr Rick Roberts, Registrar
  2. pdf Medical Error Action Group - pdf 38.50 Kb
    Ms Lorraine Long, Founder
  3. pdf Victorian Mental Illness Awareness Council - pdf 37.20 Kb
    Ms Isabell Collins, Director
  4. pdf Royal Women's Hospital - pdf 59.87 Kb
    Ms Elizabeth Kennedy, Corporate Counsel
    Ms Helen Kane, Coordinator, Reproductive Loss Services
  5. pdf Federation of Community Legal Centres and Brimbank Melton Community Legal Centre - pdf 70.00 Kb
    Ms Pauline Spencer, Executive Officer, Federation of Community Legal Centres
    Mr Charandev Singh, Human Rights Advocacy Worker, Federation of Community Legal Centres
    Mr Hugh de Kretser, Principal Community Lawyer, Brimbank Melton Community Legal Centre
  6. pdf  Victorian Institute of Forensic Medicine - pdf  110.51 Kb
    Professor Stephen Cordner, Director
    Associate Professor David Wells
    Ms Helen McKelvie, Manager, Medico-Legal Policy and Projects

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Melbourne, 20 September 2005

  1. pdf Springvale Monash Legal Service - pdf 53.13 Kb
    Mr Dave Taylor, Community Development Worker
    Mr Mark Cannon, student, Monash University
    Ms Pauline Giliberto, student, Monash University
    Mr Brendan Hodgson, student, Monash University
  2. pdf Mr Aron Gingis - pdf 57.05 Kb
  3. pdf Disability Discrimination Legal Service - pdf 42.57 Kb
    Ms Alyena Mohummadally, Community Legal Education and Volunteer Coordinator
    Ms Sarah Staub, student
  4. pdf South Pacific Foundation, Victoria - pdf 57.23 Kb
    Ms Raina Smith, Chair
    Mr George Hallet, Elder
  5. pdf Law Institute of Victoria - pdf 59.21 Kb
    Mr Bill O'Shea, Council Member
    Mr Andrew Closey, Solicitor, Criminal Law and Litigation Lawyers Section
  6. pdf Health Services Commissioner - pdf 63.81 Kb
    Ms Beth Wilson
  7. pdf Dr Ian Freckelton, Barrister and academic - pdf 69.86 Kb

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Melbourne, 28 November 2005

  1. pdf Bayside Health and The Alfred - pdf 62.02 Kb
    Mr Bill O'Shea, Corporate Counsel, Bayside Health
    Professor Catriona McLean, Director of Anatomical Pathology
  2. pdf Dr Eric Wigglesworth AM, Honorary Senior Research Fellow, Monash University Accident Research Centre - pdf 36.91 Kb
  3. pdf Austin Health - pdf 58.45 Kb
    Ms Margaret Way, Director of Strategy, Risk and Clinical Governance
    Dr Andrea Kattula, Medical Leader, Clinical Governance
    Mr Simon Rosalie, Mortuary Scientist, Austin Health
  4. pdf Victorian Institute of Forensic Medicine - pdf 109.67 Kb
    Associate Professor David Ranson, Deputy Director
    Dr Noel Woodford, Forensic Pathologist
    Ms Helen McKelvie, Manager, Medico-Legal Policy
  5. pdf Clinical Liaison Service (joint service of the Victorian Institute of Forensic Medicine and the State Coroner's Office) - pdf 74.79 Kb
    Professor Joseph Ibrahim, Research Manager
    Ms Megan Bohensky, Research Officer
    Associate Professor David Ranson, Director

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Melbourne, 5 December 2005

  1. pdf Victoria Police - pdf 40.32 Kb
    Acting Commander Trevor Carter, Policy and Secretariat Division, Corporate Strategy and Performance Department
    Senior Sergeant Anthony O'Connor, Legal Policy, Corporate Strategy and Performance Department
    Senior Constable Susan Nolan, State Coroner's Assistants' Unit, Coronial Services Centre
  2. pdf Volunteer Fire Brigades Victoria (VFBV) - pdf 33.31 Kb
    Mr Peter Davis, Executive Officer
    Mr Bob MacDonald, Executive Officer
  3. pdf Metropolitan Fire and Emergency Services Board (MFB) - pdf 43.21 Kb
    Commander Ian Hunter, Fire Investigation and Analysis Unit
  4. pdf Victorian Bar Council - pdf 52.37 Kb
    Mr Jack Forrest QC
    Mr Ross Nankivell
  5. pdf Victorian Aboriginal Legal Service (VALS) - pdf 45.83 Kb
    Mr Mike Zaccaro, Civil Law Solicitor
    Ms Greta Jubb, Research Officer
  6. pdf Country Fire Authority (CFA) - pdf 32.85 Kb
    Mr Neil Bibby, Chief Executive Officer
  7. pdf Mental Health Legal Centre - pdf 47.05 Kb
    Ms Vivienne Topp, lawyer
  8. pdf Dr Shelley Robertson - pdf 43.33 Kb
  9. pdf Registry of Births, Deaths and Marriages and Department for Victorian Communities - pdf 65.70 Kb
    Ms Helen Trihas, Registrar, Registry of Births, Deaths and Marriages
    Ms Prue Digby, Executive Director, Local Government Victoria and Community Information Division, Department for Victorian Communities

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Submissions

The Law Reform Committee received over 80 submissions for this inquiry. Most of these are available below; however, some of these submissions are confidential.

A number of people made personal submissions to the Committee. It is possible that some people may become distressed after reading some of these submissions. There are many organisations which provide telephone advice and counselling. For further information and a list of organisations visit www.betterhealth.vic.gov.au or refer to the 24-Hour Service telephone numbers in the front section of the White Pages.

  1. pdf Mr Graeme Johnson, State Coroner, State Coroner's Office of Victoria, 11 April 2005 - pdf 33.60 Kb
    (Note: Preliminary submission only. Main submission is at submission 70.)
  2. Confidential, 13 May 2005
  3. pdf Mrs Lynette King, 15 July 2005 - pdf 844.36 Kb
    pdf Mrs Lynette King - supplementary submission, 21 September 2005 - pdf 154.89 Kb
  4. pdf The Hon. Philip Ruddock MP, Commonwealth Attorney-General, 8 June 2005 - pdf 92.33 Kb
  5. Mr Julian Knight, 8 June 2005 - not available
  6. pdf Dr Patrick van der Hoeven, pathologist, 20 June 2005 - pdf 207.64 Kb
  7. pdf Ms Lorraine Long, Founder, Medical Action Error Group, 22 June 2005 - pdf 889.47 Kb
    pdf Ms Lorraine Long, Founder, Medical Action Error Group - supplementary submission, 19 September 2005 - pdf 71.89 Kb
    pdf Ms Lorraine Long, Founder, Medical Action Error Group - supplementary submission, 14 September 2005 - pdf 394.33 Kb
  8. Ms Dawn Staley, 21 June 2005 - confidential
  9. Duplicate - not available
  10. pdf SIDS and Kids Victoria, 5 July 2005 - pdf 319.52 Kb
  11. pdf Mr Cecil Watt, 5 July 2005 - pdf 203.64 Kb
  12. pdf World Federation of Doctors Who Respect Human Life - Victorian Division, 18 July 2005 - pdf 170.75 Kb
    pdf World Federation of Doctors Who Respect Human Life - Victorian Division, 3 November 2005 - supplementary submission - pdf 178.07 Kb
  13. pdf Springvale Monash Legal Service Inc, 13 July 2005 - pdf 829.33 Kb
  14. Confidential, 3 July 2005
  15. pdf Nurses Board of Victoria, 7 July 2005 - pdf 186.88 Kb
  16. pdf Radiation Advisory Committee, 4 July 2005 - pdf 819.94 Kb
  17. pdf Royal Children's Hospital, Melbourne, 24 June 2005 - pdf 987.79 Kb
  18. pdf The Royal Women's Hospital, Melbourne, 13 July 2005 - pdf 772.56 Kb
  19. pdf Dr David Leo Ranson, 14 July 2005 - pdf 4.16 Mb
  20. pdf Ms Emilia Arnus, Convenor, Representing Constitutents of East Yarra Province, 15 July 2005 - pdf 412.46 Kb
  21. pdf Victorian Surgical Consultative Council, 13 July 2005 - pdf 101.34 Kb
  22. pdf Victorian Consultative Council on Anaesthetic Mortality and Morbidity, 14 July 2005 - pdf 425.42 Kb
  23. Confidential, 14 July 2005
  24. Clinical Liaison Service, Coronial Services Centre, 6 July 2005 - confidential
  25. pdf Mrs Carol Smith, 14 July 2005 - pdf 38.95 Kb
    pdf Mrs Carol Smith - attachment, 14 July 2005 - pdf 35.87 Kb
  26. pdf Mrs Hazel Watt - pdf 162.28 Kb
  27. pdf SANE Australia, 14 July 2005 - pdf 168.33 Kb
  28. pdf Mrs Caroline Storm, 12 July 2005 - pdf 800.37 Kb
  29. pdf Disability Discrimination Legal Service Inc, 15 July 2005 - pdf 602.58 Kb
  30. pdf Mr Andrew and Mrs Karyn Kennedy, 13 July 2005 - pdf 118.33 Kb
  31. pdf Country Fire Authority (CFA), 15 July 2005 - pdf 71.55 Kb
  32. pdf Jesuit Social Services, 14 July 2005 - pdf 275.83 Kb
  33. pdf Ms Jacinta Heffey, Magistrate, Children's Court of Victoria, 12 July 2005 - pdf 1.75 Mb
  34. pdf Victoria Legal Aid, 14 July 2005 - pdf 261.00 Kb
  35. pdf Dr Shelley Robertson, 15 July 2005 - pdf 274.93 Kb
  36. pdf Volunteer Fire Brigades Victoria, 15 July 2005 - pdf 211.93 Kb
  37. pdf Dr Eleanor Flynn, 18 July 2005 - pdf 137.65 Kb
  38. pdf Australian Medical Association (AMA) Victoria, 15 July 2005 - pdf 231.24 Kb
  39. pdf Australian Nursing Federation (ANF) Victorian Branch, 15 July 2005- pdf 150.25 Kb
  40. pdf Victorian Institute of Forensic Medicine (VIFM), 19 July 2005- pdf 3.03 Mb
  41. pdf Mental Health Legal Centre Inc, 15 July 2005 - pdf 139.47 Kb
  42. pdf Maurice Blackburn Cashman Lawyers - Medical Negligence Practice Group, 18 July 2005 - pdf 635.30 Kb
  43. pdf Mrs Anne Anderson, 13 July 2005 - pdf 321.55 Kb
    pdf Mrs Anne Anderson - supplementary submission, 22 August 2005 - pdf 50.12 Kb
  44. pdf General Practice Divisions Victoria, 18 July 2005 - pdf 791.60 Kb
  45. pdf Austin Health, 19 July 2005 - pdf 462.73 Kb
  46. pdf Bayside Health, 15 July 2005 - pdf 248.87 Kb
  47. pdf The Safety Centre, Royal Children's Hospital, Melbourne, 15 July 2005 - pdf 83.77 Kb
  48. pdf Mr Graeme Bond, 16 July 2005 - pdf 88.00 Kb
    pdf Mr Graeme Bond - attachment 1, 16 July 2005 - pdf 135.56 Kb
    pdf Mr Graeme Bond - attachment 2, 16 July 2005 - pdf 51.16 Kb
    pdf Mr Graeme Bond - attachment 3, 16 July 2005 - pdf 90.46 Kb
  49. pdf Ms Marion Stevens, 25 July 2005 - pdf 539.41 Kb
  50. pdf Transport Accident Commission (TAC), 22 July 2005 - pdf 1.56 Mb
  51. pdf Australian Council for Safety and Quality in Health Care, 25 July 2005 - pdf 446.23 Kb
  52. pdf Metropolitan Fire and Emergency Services Board, 25 July 2005 - pdf 65.76 Kb
  53. pdf Life Saving Victoria - Royal Life Saving, 15 July 2005 - pdf 97.88 Kb
  54. pdf South Pacific Foundation of Victoria Inc, 15 July 2005 - pdf 368.15 Kb
  55. pdf Federation of Community Legal Centres (Vic) Inc, 22 July 2005 - pdf 1.04 Mb
  56. pdf Medical Practitioners Board of Victoria, 26 July 2005 - pdf 233.74 Kb
  57. pdf Victorian Aboriginal Legal Service (VALS), 25 July 2005 - pdf 693.34 Kb
    pdf Victorian Aboriginal Legal Service (VALS) - supplementary submission, 17 May 2006 - pdf 733.48 Kb
  58. pdf Law Institute of Victoria, 27 July 2005 - pdf 516.38 Kb
  59. pdf The Royal Australasian College of Physicians, 22 July 2005 - pdf 44.04 Kb
  60. pdf Office of the Victorian Privacy Commissioner, 2 August 2005 - pdf 578.81 Kb
  61. pdf Victorian Safe Communities Network Inc (VSCN), 4 August 2005 - pdf 191.19 Kb
    pdf Victorian Safe Communities Network Inc (VSCN) - attachment 1, 4 August 2005 - pdf 5.83 Mb
    pdf Victorian Safe Communities Network Inc (VSCN) - attachment 2, 4 August 2005 - pdf 3.50 Mb
  62. pdf Health Services Commissioner, 29 July 2005 - pdf 399.56 Kb 
  63. pdf Royal College of Nursing, Australia, 25 July 2005 - pdf 621.08 Kb
  64. pdf Transport Workers' Union (Victorian/Tasmanian Branch), 5 August 2005 - pdf 516.41 Kb
  65. pdf The Royal College of Pathologists Australasia, 19 August 2005 - pdf 179.31 Kb
    pdf The Royal College of Pathologists Australasia - attachment, 19 August 2005 - pdf 897.23 Kb
  66. pdf Mr Leon Hain, 7 August 2005 - pdf 49.96 Kb
    pdf Mr Leon Hain - supplementary submission, 13 September 2005 - pdf 190.25 Kb
  67. Numbering error - not available
  68. pdf Ms Kathleen Hurley, 15 August 2005 - pdf 537.43 Kb
  69. pdf Victoria Law Foundation, 16 August 2005 - pdf 64.92 Kb
  70. pdf Mr Graeme Johnstone, State Coroner, State Coroner's Office, 15 August 2005 - pdf 865.58 Kb
    pdf Mr Graeme Johnstone, State Coroner, State Coroner's Office - appendices, 15 August 2005 - pdf 400.89 Kb
  71. pdf Mr David and Mrs Margrit Kaufmann, 1 September 2005 - pdf 372.91 Kb
  72. pdf The Hon. Marsha Thompson MP, Minister for Consumer Affairs, Victoria, 24 August 2005 - pdf 97.24 Kb
  73. pdf State Committee of the Royal College of Pathologists Australasia, 31 August 2005 - pdf 50.43 Kb
  74. pdf Office of the Emergency Services Commissioner, 8 September 2005 - pdf 524.49 Kb
  75. pdf Transport Industry Safety Group, 13 September 2005 - pdf 85.55 Kb
  76. pdf Mr Frank Diconi, 20 September 2005 - pdf 822.01 Kb
  77. pdf The Hon. John Thwaites MP, Minister for Victorian Communities, 23 September 2005 - pdf 42.43 Kb
    pdf The Hon. John Thwaites MP, Minister for Victorian Communities - supplementary submission, 13 December 2005 - pdf 228.72 Kb
    pdf Registrar of Births, Deaths and Marriages, Department of Victorian Communities - supplementary submission, 5 May 2006 - pdf 256.78 Kb
  78. pdf Victoria Police, 7 October 2005 - pdf 482.11 Kb
  79. pdf Association for the Prevention of Medical Errors, 28 October 2005 - pdf 1.98 Mb
  80. pdf The Hon. Gavin Jennings MLC, Minister for Aboriginal Affairs, 14 November 2005 - pdf 352.37 Kb
  81. pdf The Victorian Bar, 22 December 2005 - pdf 237.68 Kb
  82. Mrs Martha and Mr Nigel Baptist, 26 January 2006 - confidential
  83. Ms Elaine Harrington, 24 March 2006 - confidential
  84. pdf Consultative Council on Obstetric and Paediatric Mortality and Morbidity, 27 July 2006 - pdf 44.78 Kb

This inquiry has been completed. No further submissions will be accepted.

Report

Discussion paper

The Law Reform Committee released a discussion paper for the Inquiry into the Review of the Coroner's Act 1985 in April 2005. The discussion paper is pdf available for download as a pdf file 607.52 Kb.

Final report

The Law Reform Committee tabled the final report for the Inquiry into the Review of the Coroner's Act 1985 in Parliament on 14 September 2006. The report is pdf available for download as a pdf file 3.33 Mb .

Media release

The Chair of the Law Reform Committee issued a media release on 14 September 2006 which is pdf available for download as a pdf file 37.22 Kb .

Government response

The Government response to the Committee's report was tabled in Parliament on 13 March 2007. The Government response is pdf available for download as a pdf file 2.90 Mb .