Hostname: page-component-8678677fb7-4qt54 Total loading time: 0 Render date: 2026-10-25T08:01:29.804Z Has data issue: false hasContentIssue false
  • English
  • Français

Exploring fatal facts: current issues in coronial law, policy and practice

Published online by Cambridge University Press:  22 June 2016

Rebecca Scott Bray  and
Greg Martin
Get access ImageRights & Permissions [Opens in a new window]

Abstract

Death investigation and coronial practices have undergone significant social, political and legal scrutiny in recent years. A wave of coronial reform has occurred across jurisdictions, including in the United Kingdom (UK), Australia, Canada and New Zealand, with a concomitant focus on the adequacy of death investigation law and policy. Taking key coronial developments in the UK and Australia as its starting point, this paper explores a legal jurisdiction undergoing immense legal and policy reform to illustrate why coronial law and practice is of increasing scholarly interest. It begins by tracing the contentious landscape of UK coronial law reform, which has also resonated internationally, thereafter examining key controversies that refocused attention on the value of the jurisdiction, before discussing contemporary coronial issues including, publicity, human rights and death prevention.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Amnesty International (2015) ‘Review of the Implementation of the Recommendations of the RCIADIC Recommendations’, in The Adequacy of Post Death Investigations (Recommendations 6–40). Online: <https://changetherecord.org.au/review-of-the-implementation-of-rciadic-may-2015> (last accessed 10 April 2016).+(last+accessed+10+April+2016).>Google Scholar
Australian Inquest Alliance (Aia) (2011) Submission to the National Human Rights Action Plan Baseline Study Consultation. Victorian Aboriginal Legal Service. Online: <http://www.vals.org.au/assets/2015/06/Australian-Inquest-Alliance-submission-to-the-National-Human-Rights-Action-Plan-Draft-Baseline-Study-Consultation.pdf> (last accessed 10 April 2016).+(last+accessed+10+April+2016).>Google Scholar
Baer Arnold, Bruce and Bonython, Wendy (2016) ‘Autopsies, Scans and Cultural Exceptionalism’, Alternative Law Journal 41(1): 27–30.CrossRefGoogle Scholar
Barnes, Michael, Kirkegaard, Ainslie and Carpenter, Belinda (2014) ‘Intake Rigour: Ensuring only “Reportable Deaths” Become Coroners’ Cases’, Journal of Law and Medicine 21(3): 572–583.Google ScholarPubMed
Brazier, Margaret (2002) ‘Retained Organs: Ethics and Humanity’, Legal Studies 22(4): 550–569.CrossRefGoogle Scholar
Brazier, Margaret (2003) ‘Organ Retention and Return: Problems of Consent’, Journal of Medical Ethics 29: 30–33.CrossRefGoogle Scholar
Brazil, Raymond (2011) ‘The Coroner's Recommendation: Fulfilling its Potential? A Perspective from the Aboriginal Legal Service (NSW/ACT)’, Australian Indigenous Law Review 15(1): 94–100.Google Scholar
Bugeja, Lyndal, Ibrahim, Joseph E., Ferrah, Noha, Murphy, Briony, Willoughby, Melissa and Ranson, David (2016) ‘The Utility of Medico-Legal Databases for Public Health Research: A Systematic Review of Peer-Reviewed Publications Using the National Coronial Information System’, Health Research Policy and Systems 14: online: <http://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-016-0096-1>.CrossRefGoogle ScholarPubMed
Bugeja, Lyndal and Ranson, David (2003) ‘Coroners’ Recommendations: Do They Lead to Positive Public Health Outcomes?’, Journal of Law and Medicine 10(4): 399–400.Google ScholarPubMed
Carpenter, Belinda and Tait, Gordon (2009) ‘Health, Death and Indigenous Australians in the Coronial System’, Aboriginal Australian Studies 1: 29–41.Google Scholar
Carpenter, Belinda, Tait, Gordon, Adkins, Glenda, Barnes, Michael, Naylor, Charles and Begum, Nelufa (2011) ‘Communicating with the Coroner: How Religion, Culture, and Family Concerns May Influence Autopsy Decision Making’, Death Studies 35(4): 316–337.CrossRefGoogle ScholarPubMed
Carpenter, Belinda, Tait, Gordon, Quadrelli, Carol and Drayton, John (2015) ‘Scrutinising the Other: Incapacity, Suspicion and Manipulation in a Death Investigation’, Journal of Intercultural Studies 36(2): 113–128.CrossRefGoogle Scholar
Carrington, Kerry, HOGG, Russell and SOZZO, Máximo (2016) ‘Southern Criminology’, British Journal of Criminology 56(1): 1–20.CrossRefGoogle Scholar
Carroll, Robert, Hawton, Keith, Kapur, Nav, Bennewith, Olive and Gunnell, David (2011) ‘Impact of the Growing Use of Narrative Verdicts by Coroners on Geographic Variations in Suicide: Analysis of Coroners’ Inquest Data’, Journal of Public Health 34(3): 447–453.CrossRefGoogle ScholarPubMed
Coles, Deborah and Shaw, Helen (2012) Learning from Death in Custody Inquests: A New Framework for Action and Accountability. London: INQUEST.Google Scholar
Davis, Gwynn, Lindsey, Rose, Seabourne, Gwen and Griffiths-Baker, Janine (2002) Experiencing Inquests, Home Office Research Study 241. London: United Kingdom Home Office Research, Development and Statistics Directorate.Google Scholar
Dewar, S. and Boddington, P. (2004) ‘Returning to the Alder Hey Report and Its Reporting: Addressing Confusions and Improving Inquiries’, Journal of Medical Ethics 30: 463–469.CrossRefGoogle Scholar
Freckelton, Ian (2009) ‘Opening a New Page’, Law Institute Journal 83(6): 28–33.Google Scholar
Freckelton, Ian (2010) ‘Anglo-Australian Coronial Law Reform: The Widening Gap’, Journal of Law and Medicine 17(4): 471–480.Google ScholarPubMed
Freckelton, Ian and Mcgregor, Simon (2014) ‘Coronial Law and Practice: A Human Rights Perspective’, Journal of Law and Medicine 21(3): 584–601.Google Scholar
Freckelton, Ian and Ranson, David (2006a) Death Investigation and the Coroner's Inquest. Melbourne: Oxford University Press.Google Scholar
Freckelton, Ian and Ranson, David (2006b) ‘The Evolving Institution of Coroner’, in Freckelton, Ian and Peterson, Kerry (eds), Disputes and Dilemmas in Health Law. Sydney: Federation Press, 296–323.Google Scholar
Goldson, Barry (2006) ‘Fatal Injustice: Rampant Punitiveness, Child Prisoner Deaths, and Institutionalized Denial – A Case for Comprehensive Independent Inquiry in England and Wales’, Social Justice 33(4): 52–68.Google Scholar
Gordon, Daniel (2014/2016) (Dir.) Hillsborough VeryMuchSo/Passion Pictures.Google Scholar
Halstead, Boronia (1998) ‘Coroners’ Recommendations Following Deaths in Custody’, in Selby, Hugh (ed.), The Inquest Handbook. Leichhardt, NSW: Federation Press, 186–205.Google Scholar
Harris, John (2002) ‘Law and Regulation of Retained Organs: The Ethical Issues’, Legal Studies 22(4): 527–549.CrossRefGoogle ScholarPubMed
Hill, Chris and Cook, Lois (2011) ‘Narrative Verdicts and Their Impact on Mortality Statistics in England and Wales’, Health Statistics Quarterly 49: 81–100.CrossRefGoogle Scholar
Hillsborough Independent Panel (2012) Hillsborough: The Report of the Hillsborough Independent Panel. London: Stationery Office.Google Scholar
Human Rights Law Centre (Hrlc) (2008) In the Coroners Court of Victoria, Inquest into the Death of Tyler Cassidy, Submissions of the Human Rights Law Resource Centre. Online: <http://www.hrlrc.org.au/files/Closing-Submissions-of-the-HRLRC-redacted.PDF> (last accessed 10 April 2016).+(last+accessed+10+April+2016).>Google Scholar
Human Rights Law Centre (Hrlc) (2013) Individual Communication to the United Nations Human Rights Committee by Shani Cassidy, 29 May 2013. Online: <http://www.hrlc.org.au/wp-content/uploads/2013/05/UN_Communication_regarding_TylerCassidy_May2013.pdf> (last accessed 10 April 2016).+(last+accessed+10+April+2016).>Google Scholar
Human Rights Law Centre (Hrlc) (2015) Individual Communication to the United Nations Human Rights Committee by Shani Cassidy, 10 March 2015. Online: <http://hrlc.org.au/wp-content/uploads/2015/03/Reply_to_Australian_Governement_Submission.pdf> (last accessed 10 April 2016).+(last+accessed+10+April+2016).>Google Scholar
Hunyor, Johnathon (2008) ‘Human Rights in Coronial Inquests’, Australian Indigenous Law Review 12(SE2): 64–74.Google Scholar
Hunyor, Johnathon (2009) ‘Disgrace: The Death of Mr Ward’, Indigenous Law Bulletin 7(15): 3–8.Google Scholar
Inquest (2002) How the Inquest System Fails Bereaved People: INQUEST's Response to the Fundamental Review of Coroner Services London: INQUEST.Google Scholar
Inquest (2015a) Deaths in Mental Health Detention: An Investigation Framework Fit for Purpose? London: INQUEST.Google Scholar
Inquest (2015b) Stolen Lives and Missed Opportunities: The Deaths of Young Adults and Children in Prison. London: INQUEST and Barrow Cadbury Trust.Google Scholar
Liddell, Kathleen and Hall, Alison (2005) ‘Beyond Bristol and Alder Hey: The Future Regulation of Human Tissue’, Medical Law Review 13: 170–223.CrossRefGoogle Scholar
Luce, Tom (2007) ‘Reform of the Coroner System and Death Certification’, British Medical Journal 335: 680–681.CrossRefGoogle ScholarPubMed
Lynch, Matthew J. and Woodford, Noel W. F. (2007) ‘Objections to Medico-Legal Autopsy – Recent Developments in Case Law’, Journal of Law and Medicine 14(4): 463–468.Google ScholarPubMed
Lynch, Matthew J. and Woodford, Noel W. F. (2014) ‘The Role of Post-Mortem Imaging in Preliminary Examinations Under the Coroners Act 2008 (VIC): A Forensic Pathologist's Perspective’, Journal of Law and Medicine 21(4): 774–779.Google ScholarPubMed
Malbon, Justin (1998) ‘Institutional Responses to Coronial Recommendations’, Journal of Law and Medicine 6: 35–49.Google Scholar
Martin, Greg and Scott Bray, Rebecca (2013) ‘Discolouring Democracy? Policing, Sensitive Evidence, and Contentious Deaths in the United Kingdom’, Journal of Law and Society 40(4): 624–656.CrossRefGoogle Scholar
Mason, J. K. and Laurie, G. T. (2001) ‘Consent or Property? Dealing with the Body and Its Parts in the Shadow of Bristol and Alder Hey’, Modern Law Review 64(5): 710–729.CrossRefGoogle ScholarPubMed
Mckeough, Jill (1983) ‘Origins of the Coronial Jurisdiction’, University of New South Wales Law Journal 6: 191–210.Google Scholar
Mok, Elena (2014) ‘Harnessing the Full Potential of Coroners’ Recommendations’, Victoria University of Wellington Law Review 45(2): 321–365.CrossRefGoogle Scholar
Moore, Jennifer (2014) ‘An Empirical Approach to the New Zealand Government's Review of the Coronial Jurisdiction’, Journal of Law and Medicine 21(3): 602–626.Google Scholar
Pearse, Jessica and Daking, Leanne (2007) ‘The National Coroners Information System: Contributing to Death and Injury Prevention’, Health Information Management Journal 36(2): 54–57.CrossRefGoogle ScholarPubMed
Price, David (2003) ‘From Cosmos and Damian to Van Velzen; The Human Tissue Saga Continues’, Medical Law Review 11: 1–47.CrossRefGoogle Scholar
Prictor, Megan (2012) ‘The Sideshow or the Circus? The Role for Public Interest Organisations at Inquests’, Journal of Law and Medicine 20(2): 320–332.Google ScholarPubMed
Prison Reform Trust/Inquest (2012) Fatally Flawed: Has the State Learned Lessons from the Deaths of Children and Young People in Prison? Prison Reform Trust: London.Google Scholar
Ranson, David (2010) ‘The Coroners Act 2008 (Vic): A Medical Investigator's Perspective’, Journal of Law and Medicine 17(4): 487–492.Google ScholarPubMed
Rciadic (Royal Commission into Aboriginal Deaths in Custody) (1991) National Report, Vol. 1. Online: <http://www.austlii.edu.au/au/other/IndigLRes/rciadic/national/vol1/> (last accessed 14 November 2015).+(last+accessed+14+November+2015).>Google Scholar
Renteln, Alison Dundes (2002) ‘The Rights of the Dead: Autopsies and Corpse Mismanagement in Multicultural Societies’, South Atlantic Quarterly 100(4): 1005–1027.CrossRefGoogle Scholar
Scott Bray, Rebecca (2008) ‘Why This Law?’ Vagaries of Jurisdiction in Coronial Reform and Indigenous Death Prevention’, Australian Indigenous Law Review 12(SE 2): 27–44.Google Scholar
Scott Bray, Rebecca (2010) ‘Death Scene Jurisprudence: The Social Life of Coronial Facts’, Griffith Law Review 19(3): 567–592.CrossRefGoogle Scholar
Scott Bray, Rebecca (2012) ‘Executive Impunity and Parallel Justice? The United Kingdom Debate on Secret Inquests and Inquiries’, Journal of Law and Medicine 19(3): 569–592.Google Scholar
Scott Bray, Rebecca (2013) ‘Paradoxical Justice: The Case of Ian Tomlinson’, Journal of Law and Medicine 21(2): 447–472.Google Scholar
Scraton, Phil (1999) ‘Policing with Contempt: The Degrading of Truth and Denial of Justice in the Aftermath of the Hillsborough Disaster’, Journal of Law and Society 26(3): 273–297.CrossRefGoogle Scholar
Scraton, Phil and Chadwick, Kathryn (1987) In the Arms of the Law: Coroner's Inquests and Deaths in Custody. London: Pluto Press.Google Scholar
Selket, K., Glover, M. and Palmer, S. (2015) ‘Normalising Post-mortems – Whose Cultural Imperative? An Indigenous View of New Zealand Post-Mortem Policy’, Kotuitui: New Zealand Journal of Social Sciences Online 10(1): 1–9.Google Scholar
Skene, Loane, (2002a) ‘Proprietary Rights in Human Bodies, Body Parts and Tissue: Regulatory Contexts and Proposals for New Laws’, Legal Studies 22: 102–127.CrossRefGoogle Scholar
Skene, Loane (2002b) ‘Ownership of Human Tissue and the Law’, Nature Reviews Genetics 3: 145–148.CrossRefGoogle ScholarPubMed
Skene, Loane (2007) ‘Legal Rights in Human Bodies, Body Parts and Tissue’, Journal of Bioethical Inquiry 4: 129–133.CrossRefGoogle Scholar
Sutherland, Georgina, Kemp, Celia, Bugeja, Lyndal, Sewell, Graham, Pirkis, Jane, and Studdert, David M. (2014) ‘What Happens to Coroners’ Recommendations for Improving Public Health and Safety? Organisational Responses under a Mandatory Response Regime in Victoria, Australia’, BMC Public Health 14: 732–739.CrossRefGoogle Scholar
Tait, Gordon, Carpenter, Belinda, De Leo, Diego and Tatz, Colin (2015) ‘Problems with the Coronial Determination of Suicide’, Mortality 20(3): 233–247.CrossRefGoogle Scholar
Tait, Gordon, Carpenter, Belinda, Quadrelli, Carol and Barnes, Michael (2016) ‘Decision-making in a Death Investigation: Emotion, Families and the Coroner’ Journal of Law and Medicine 23(3): 571–581.Google Scholar
Thomas, Leslie, Straw, Adam, Machover, Daniel and Friedman, Danny (2014) Inquests: A Practitioner's Guide. London: Legal Action Group.Google Scholar
Trabsky, Marc and Baron, Paula (2016) ‘Negotiating Grief and Trauma in the Coronial Jurisdiction’, Journal of Law and Medicine 23(3): 582–594.Google ScholarPubMed
Vines, Prue (2000) ‘Objections to Post-Mortem Examination: Multiculturalism, Psychology and Legal Decision-Making’, Journal of Law and Medicine 7(4): 422–433.Google Scholar
Vines, Prue (2007) ‘The Sacred and the Profane: The Role of Property Concepts in Disputes about Post-Mortem Examination’, Sydney Law Review 29(2): 235–261.Google Scholar
Vines, Prue and Mcfarlane, Olivia (2000) ‘Investigating to Save Lives: Coroners and Aboriginal Deaths in Custody’, Indigenous Law Bulletin 4(27): 8–13.Google Scholar
Watterson, Ray, Brown, Penny and Mckenzie, John (2008) ‘Coronial Reform and the Prevention of Indigenous Death’, Australian Indigenous Law Review 12(SE2): 4–26.Google Scholar
Wells, Celia (1996) ‘Disasters: The Role of Institutional Responses in Shaping Public Perceptions of Death’, in Lee, Robert and Morgan, Derek (eds), Death Rites: Law and Ethics at the End of Life. London: Routledge, 197–214.Google Scholar