Advocates' calls for a dedicated coroner remain unanswered as the ACT government considers nine potential reforms to the coronial system.
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The proposals include the introduction of a family liaison officer, and the creation of an online register containing coronial reports that raise matters of public safety. The register would also detail government responses to those issues.
The measures under consideration also include incorporating restorative practices into the coronial process and conducting hearings with as little formality as possible in an effort to make the ACT's maligned system more accessible, timely and transparent for families.
Families have been at the forefront of calls for change, with Canberra women Rosslyn Williams, Ann Finlay and Eunice Jolliffe forming the Coronial Reform Group to lead the charge. All three women had bad experiences with the coronial system after the death of a son.
Ms Williams said they had found the process "disempowering, re-traumatising and ultimately ineffective".
She welcomed the proposed reforms and said the group now wanted to see the ideas implemented.
But Ms Williams said the ACT was still in "desperate need" of a dedicated coroner to take the lead on transitioning towards a restorative system. She said it would replace what is sometimes an adversarial atmosphere during inquests with a co-operative approach that balanced families' grief with the need to prevent future deaths.
"Running a coronial inquest is quite different from normal court procedures, so at the moment with different magistrates acting as coroners you get no consistency of approach," Ms Williams said.
"If you had a dedicated coroner, that's going to solve a lot of problems because they'll have specialist skills.
"It would also solve the other huge issue in the ACT, which is that of timeliness."
Ms Williams said some families had waited seven years for findings to be handed down, dragging out grief and creating a situation where others might die in the meantime because of unaddressed safety issues.
Former ACT chief coroner Lorraine Walker, who is now an acting judge, has called on multiple occasions for a dedicated coroner to be appointed.
ACT Attorney-General Gordon Ramsay recently convened a coronial reform forum, at which the government's nine proposed reforms were revealed and discussed.
This journalist requested an invitation to the forum, but Mr Ramsay's office said media would not be invited because the subject matter was sensitive.
Speakers at the event included Mr Ramsay, the Coronial Reform Group, ACT Acting Chief Coroner Glenn Theakston, former NSW state coroner Michael Barnes, and ex-NSW deputy state coroner Hugh Dillon.
In Mr Ramsay's speaking notes, provided by his office, he acknowledged the coronial process could cause grieving families' pain to be re-lived.
Mr Ramsay said the government wanted to embed restorative practices in not only the coronial system but in systems across the ACT, with the goal of making Canberra a restorative city.
In a coronial sense, he said this might include the court giving more time to cases that needed it, community organisations working more collaboratively with the court to support families, and the government listening to the people most affected in addressing issues that resulted from deaths.
"There are many benefits to [a restorative] approach," Mr Ramsay said.
"Other cities doing this work around the world have seen increases in wellbeing, decreases in crime and antisocial behaviour, improvements in health and achievement across a range of areas."
Former NSW deputy state coroner Hugh Dillon said coronial reform was rare in Australia, and the ACT was a particularly rare case because so many affected families were engaged in pushing for change.
He also supported calls for a dedicated coroner but described the proposed introduction of a family liaison officer as the "single best and most effective reform that the ACT government could institute".
Mr Dillon said courts churned through such a high volume of cases that they could easily lose sight of the fact they involved real people and their suffering.
"We cannot equate their situations with the complaints of people who are appealing a parking fine, for instance," he said.
"This is something that is comprehensively different about the coronial process [when compared with other courts].
"The reason the liaison idea is so important is that most of the families who have been up in arms about the system have bad experiences because they've not been kept informed, or they've been misinformed even. They have felt left out of the loop."
Mr Dillon said family liaison officers had been invaluable to coroners in NSW.