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Coroners’ Courts Must Improve their Responses to Suicides of Aboriginal and Torres Strait Islander People

4 October 2023: A national system of accountability is needed to ensure findings by coroners are used to inform suicide prevention measures for Aboriginal and Torres Strait Islander people, according to the results of an Australian-first research project released today.

The project report, Coronial Responses to Suicides of Aboriginal and Torres Strait Islander People, also calls for:

  • Identified liaison roles to support Aboriginal and Torres Strait Islander families in all coroners’ courts, staffed by Aboriginal and Torres Strait Islander people.
  • Ongoing cultural training and oversight for Coroners and their staff, provided by Indigenous people.
  • Revision of information brochures and other written communications by Coroners’ courts, to make them appropriate for Indigenous people.
  • Law reform where required to ensure Coroners consider Aboriginal and Torres Strait Islander cultural requirements, such as in establishing a person’s next of kin.

Professor Pat Dudgeon, the Director of the Centre for Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) and the report’s lead author, said, “These findings make a clear case for immediate investment in the capacity of coronial systems to respond to the needs of our people. It is simply unacceptable that Aboriginal and Torres Strait Islander families, who lose loved ones to suicide at more than double the rate of other Australians, have to go through a system that does not recognise their culture and that many find intimidating and alienating.”

Professor Dudgeon said a national system should be established to examine suicides of Aboriginal and Torres Strait Islander people, identifying patterns in the time leading up to the event and using that information to develop targeted prevention strategies. Such a system could be modelled on the Australian Domestic and Family Violence Death Review Network, which looks in detail at all family violence deaths and makes recommendations for systemic change she said.

“The Australian Bureau of Statistics last week released data showing Indigenous suicides were at their highest rate ever in 2022 and have continued to rise for well over a decade,” said Professor Dudgeon. “It is time for all jurisdictions to acknowledge that Aboriginal and Torres Strait Islander suicide is a crisis, and respond accordingly by investing in the solutions proposed in our report.” She said the recommendations could play a part in preventing future suicides by:

  • Identifying emerging Indigenous suicide trends, so they could be addressed through prevention measures;
  • Better supporting families and communities at a time of profound distress, to reduce the likelihood of additional “cluster” suicides; and
  • More accurately identifying Indigenous suicides, which the ABS says may be under-reported, and advocating for fair funding based on the real impact.

Professor Dudgeon said it was encouraging that coroners recognised the need for their courts to improve their cultural capacity to respond to Aboriginal and Torres Strait Islander families. “Many coroners mentioned the same issues identified by Indigenous family members, but their hands are tied by inadequate funding and inflexible legislation,” she said. “I hope that our report encourages governments to invest in the system so our people have better experiences and coroners and their staff can develop the skills they need.”

The CBPATSISP’s report is based on the perspectives of Aboriginal and Torres Strait Islander people who have been bereaved by suicide, and on interviews with coroners, community organisations and others with a personal or professional interest in Indigenous suicide. This included a workshop with Aboriginal and Torres Strait Islander family members who have lost loved ones to suicide, convened in collaboration with the Aboriginal and Torres Strait Islander Lived Experience Centre (ILEC), part of the Black Dog Institute (BDI). The lived experience group also developed a companion report, which is also published today as part of the research.

Vicki McKenna, the Head of the ILEC, said it was essential to ensure families’ experiences were conveyed directly, in their own words. The workshop group members had gone through, “an enormous emotional journey, sharing their lived experience through this research with the possibility of shaping how the coroners’ courts respond to Indigenous people in future,” she said.

“Members of the workshop group told us the coroners didn’t really understand their culture and didn’t always show respect,” Ms McKenna said. “They didn’t know about men’s and women’s business or our practices and rituals after someone has passed away. Some of the group said they found the whole process intimidating. The coroner is a court, and lots of our people have had bad experiences with courts.”

Ms McKenna said coroners should learn about the culture of the communities in their state or region, meeting Elders and make a connection with them, using appropriate language and having welcoming spaces. Above all, she said, “people want their loved one’s life to matter. We want their passing and everything that happened at the time to be used to prevent other suicides.”

The Victorian Coroner’s Aboriginal Engagement Unit had already implemented many measures to support Indigenous families and assist the coroners in investigating Indigenous passings, and could provide a template for other jurisdictions, Ms McKenna said. “Now it is up to governments to fund coroners’ offices so they can implement these reforms,” she said.

  • The Coronial Responses to Suicides of Aboriginal and Torres Strait Islander People research program was funded by the National Suicide Prevention Office.

Read the reports here.

Download the slides from the report launch webinar here. Alternatively, the slides are provided below for your convenience.

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If you or someone you know needs help or support, you can contact your local Aboriginal Community-Controlled Organisation or

  • 13YARN: 13 92 76
  • Lifeline: 131 114
  • Kids Helpline: 1800 551 800
  • Mensline: 1300 78 99 78
  • Beyondblue 1300 22 46 36
  • Q Life 1800 18 45 27
  • Open Arms Veterans & Families Counselling 1800 01 10 46
  • The National Indigenous Critical Response Service 1800 80 58 01
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