HON ALISON XAMON (North Metropolitan) [9.58 pm]: Last week, I received some answers to questions I had asked about what was happening with coronial delays and I was really disappointed to learn, through the answers that I received, that the backlog of coronial cases has grown to 540. Backlog cases are those that have been in the system for longer than 12 months and as of 30 June 2019, the backlog stood at 458. It is really frustrating that despite efforts to address this backlog—I do want to recognise that there has been some effort—this number has increased by more than 80 cases since last year and represents an increase of over 50 per cent since 2016–17 when we had 347 cases. Of those 540 cases, 118 are subject to an inquest, 30 pertain to deaths in custody and 25 are suspected suicides. They are really tragic circumstances for families that are still waiting to get answers. They are really important cases. The number that has been in the system for over 12 months is simply too high. We are effectively talking about 540 families that have been kept in limbo for far too long.

I acknowledge that delays are often not the fault of the Coroner’s Court. The answer to the question demonstrated that 32 of the current backlog cases are delayed because the coroner is still waiting for reports from external agencies such as ChemCentre, PathWest and the WA Police Force. Whatever the reason, members would have to agree that it is really not good enough. In WA, the Coroner’s Court has a particularly important and challenging role, including speaking for some of our most vulnerable citizens.

The coronial court provides much-needed advice to families and loved ones, including—this is probably the bit that is most important to me—providing advice when changes might be introduced so that we can ensure that similar deaths will not occur in the future. The annual report of the Coroner’s Court has a really good quote. It states —

It is said that the role of the Coroner’s Court is to speak for the dead and to protect the living. This two fold role is a vital component of a civil society.

That really sums up why it is so critical that we get this particular court right. The coroner’s findings on deaths in custody and deaths of people who are held in care are particularly important. This includes involuntary mental health patients as well as children who are in and out of home care. In addition to identifying ways to protect deaths in the future, inquests can be really important ways to identify where our police or our departmental staff may have got it tragically wrong. It also has the effect of exonerating them from wrongdoing and answering really important questions that the family and those left behind grieving might have. It is obviously really concerning when we are waiting an average of two to three years to learn from these deaths. The delays considerably add to the stress of families and loved ones in a time of grief. Practically, they also impact on people’s capacity to settle insurance and financial affairs. Whichever way we look at it, the longer the process takes, the longer it will take to address any of those recommendations. It is also concerning to consider whether delays in beginning inquest investigations for more than 12 months after a death will impact on the quality of the inquest process. We have to remember that people change jobs and memories become dim.

There are obviously many issues with delays and backlogs. There is also concern that this rising backlog may impact on the capacity of the coroner to undertake discretionary inquests, which are important inquests related to public health and safety issues. For example, families of workers who have been killed are desperate to get answers as well. This is not a new issue. Coronial delays have been widely acknowledged for a long time, going as far back as 2008 with the Law Reform Commission of Western Australia’s “Review of Coronial Practice in Western Australia”. A very long time ago people were talking about the need for reform. Concerns continue to be raised with me in my role as a member of Parliament by grieving families, particularly families grieving for people who have died in custody as well as people who have suicided after seeking mental health care. It seems that a disproportionate number of families come to me about those sorts of matters.

As I said, I recognise that there has been some progress. We have an additional coroner, a CT scanner and some IT improvements. Those IT improvements were long overdue. At the time the 2018–19 annual report was written, the coroner did not even have an electronic case management system, which defies belief, but I am hoping that that has now been rectified. Despite the fact that these improvements have been made, we still have a worsening backlog of cases, which shows that we are not even touching the sides.

I want to note some important recommendations from recent inquests, particularly those about the child RM, who died by suicide at 17 years of age and was tragically failed by our child protection system. The coroner’s report and subsequent recommendations have been incredibly important, but are also heartbreaking. This young woman died in April 2017, but the inquest findings were delivered only in July this year. Also important are the recommendations made following the death of Hayden Stacey, who was shot by police. I note the coroner’s finding that we urgently need a more effective taser system. The recommendations were delivered only last month, but Mr Stacey died in May 2018. The important recent findings from the inquest into the death of Jessica Lindsay, who was trying to lose weight for an amateur Muay Thai fight, were made only last month. However, Jessica died in November 2017. Some really important recommendations were made by the coroner about combat sports culture needing to change.

Coronial inquests can prevent further deaths, so it is really important that we finally become able to hold inquests in a timely manner and that the recommendations are addressed quickly and in full by government departments. I note that the coroner recommended improvements in mental health services in prisons more than three years ago, yet it has taken more deaths for those recommendations to be even started upon. Coronial backlogs are a distressingly perennial issue, but we are going in the wrong direction. There have been improvements, but, clearly, we have to start urgently looking at the recommendations that came out in full back in 2008 because the situation is not improving. We need to make sure that families get answers and that we get the answers we need to ensure that we do not have unnecessary deaths in the future.


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