“We’re walking this path that nobody wants to be… it’s the most excruciating pain, compounded by pushing our way through this broken system.”
In a report released in AprilA NSW parliamentary inquiry recommended a major reform of the coronary system, including the establishment of the Coroners Court as an “autonomous and specialized court”, similar to the Children’s Court.
NSW does not have a self-contained specialist Coroners Court, but uses a hybrid model, administered by the Local Court, where six full-time coroners work in Sydney, and state and regional magistrates act as part-time coroners in the rest of the country. the state.
A judicial inquiry into an incident like this should have been a good idea.
Jacqueline Quinlivan, whose husband Lyndon was killed in a work-related accident in 2018.
The state was “the only jurisdiction in Australia where magistrates and court clerks continue to take coronary responsibilities,” the NSW Bar Association said, and the court was significantly under-resourced, with just six specialist coroner positions compared to 14 in Victoria.
The parliamentary committee also called for additional dedicated coroners, including at least one full-time coroner for each region. “Regional magistrates should no longer be required to perform any coronary duties,” the report said.
In a response last week, the government noted the plan but made no commitment to it. It said it would “continue to assess opportunities to strengthen the structure and operations of the coronary jurisdiction in NSW”.
In a separate incident on the NSW Mid North Coast, Tony Coulston vomited blood and died after falling from his hospital bed in 2021.
His family was denied an inquest, although an internal investigation by Port Macquarie Base Hospital revealed multiple deficiencies in Coulston’s care.
Tony’s daughter, Christina Coulston, said for the record, the government should explain why it would not implement all of the investigation’s recommendations.
“Is it budgetary or that a lot of system flaws they don’t want to address would come to light?” she said.
“Our family sees the NSW government’s response to the parliamentary inquiry as more of the same – more inequality for rural and regional communities, forced to accept the appalling standard of health care, preventable deaths and cover-ups.”
George Newhouse, chief executive and lead attorney for the National Justice Project, said the government’s response was disappointing and “grieving families deserve better”.
“They deserve a coronary system that can bring justice through truth, accountability and prevention,” he said.
The government has not committed to further funding to the court, beyond an existing 2021-22 budget commitment for an additional magistrate assigned exclusively to coronary jurisdiction and funding for a case management unit.
Our family sees the NSW government’s response to the… inquiry as more of the same – more inequality for rural and regional communities
Christina Coulston, whose father Tony died after falling from his hospital bed in 2021.
Former NSW Deputy NSW Coroner Hugh Dillon, who has long advocated a shake-up of the state’s “aging” coronary system, said: “Nearly half of reported deaths occur in rural and regional NSW. Health statistics show that the early and preventable death rates in the country are higher than in Sydney.
“Nevertheless, magistrates nationwide conduct few investigations and, on average, make recommendations for death prevention only three times a year. They are expected to carry heavy criminal workloads and handle corona cases. They can’t do both.”
Bar Association President Gabrielle Bashir, SC, called on the government to reconsider its position.
The Aboriginal Legal Service described the government’s response to the investigation as “extremely disappointing,” including not supporting a recommendation to require coroners to investigate whether systemic problems played a role in a death.
“Taking down a recommendation is essentially putting it on the back burner,” said lead attorney Nadine Miles.
Upper House Labor MP Adam Searle, who chaired the parliamentary inquiry, said the jurisdiction needed additional resources “urgently”.
“The crisis in jurisdiction is more pronounced in rural and regional NSW. The need for all communities in NSW to have full-time coroners looking after their cases is urgent and needs to be urgently addressed,” he said.
Attorney General Mark Speakman said “resources and structural matters related to coronary jurisdiction are still under review”.
“The NSW government recognizes the trauma and grief experienced by families and communities affected by an unexpected or unexplained death and remains committed to strengthening our coronary jurisdiction,” he said.
He said the government had carefully considered the report and was pleased to support, or support in principle, 15 of the 35 recommendations. It had already established a task force before the study to reduce delays and improve families’ experiences.
A series of reforms were already underway, such as changes “to make it easier to navigate the coronary pathway for grieving families and friends, including those in regional locations, and to support the court’s efforts to reduce preventable deaths and make our community safer.” to make”.
“The NSW Coroners Court continues to lead the nation in the timing of the results,” he said.
“According to the 2021 Government Services Report data, the court has completed 87.5 percent of cases under 12 months and 96.6 percent under 24 months, both the highest of comparable jurisdictions.”
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