Nearly one quarter of inquests in Australia run for more than three years, which may lead to delays in implementing coroners’ recommendations and prolong families’ grief, a study has found.
Researchers from Stanford University in the US and the University of Melbourne examined the timelines of 5,096 inquests held in Australia between 1 January 2007 and 31 December 2013.
Although the definition of deaths that qualify for an inquest varies between jurisdictions, generally all unexpected, unnatural or violent deaths are reported to the coroner.
Inquests seek to determine what, if anything, could be changed to prevent similar deaths from occurring again. Recommendations are not legally binding, but their implementation can increase public safety.
The researchers found the cases they examined took a median time of 1.6 years to close, although 40% took more than two years to close, 22% more than three years, 12% more than four years, and 6% more than five years.
The leader of the study and a professor of medicine and law, David Studdert, said it was the first to examine cases that took especially long to close, which he said was important given delays in inquests could undermine the reliability of witness testimony and prolong public exposure to preventable risks.
“Families will be dissatisfied with inquests that are rushed and ill-considered,” he said. “So that is clearly not the solution.
“On the other hand, three or four years seems just too long to wait. England and Wales recently set one year as an expected closure time for inquests – after that, coroners are required to explain why it is taking longer.
“A year will be too fast for some complex cases, but for many it’s probably a reasonable target.”
The researchers also found substantial variation in the time an inquest took depending on the state or territory where it occurred. Cases in the Northern Territory closed the fastest. At four years, 2% of cases remained open in the Northern Territory compared with 7% in New South Wales and 18% in Victoria and South Australia.
The study did not look into the causes of differences in time between jurisdictions. However, the authors discussed a number of reasons for so many inquests taking more than three years to close.
“Coroners have pointed to resourcing issues, particularly insufficient staff, as well as deficient information technology and the tardy provision of information needed to conclude their investigation,” the authors wrote.
To address preventable delays, the authors called for: improved auditing, transparency and public accountability in relation to case backlogs; closer oversight by the chief coroner on cases that are open for more than one year; fast-tracking criminal investigations; increased resourcing and better communication with families on the progress of investigations.
A Shine Lawyers senior solicitor, Paula Shelton, has worked on many high-profile inquests, including for the families of Luke Batty and Kelly Thompson. She said delays to inquests affected family members in particular.
“It’s a huge issue,” she said. “I’ve run five inquests in the last 18 months and all except one were significantly affected by the length of time.
“I don’t think families can start to move on until it’s over. They have already had to try to process losing a loved one which is traumatic enough and it re-traumatises them every time something else happens in the inquest.”
She said inquests routinely went for more than three years. She said she began work on an inquest last week involving a child who had died three years earlier, in 2013. Another inquest she received findings for recently had begun six years earlier.
Delays could occur when police took inadequate statements from witnesses at the time of the death, meaning statements needed to be retaken or more witnesses called, she said.
“However, I think it is really an issue of resources,” Shelton said.
“There are plenty of really good people and investigators and counsel assisting at the coroner’s court, but they are underresourced.”
The research also found deaths due to assault generally took one year longer to close than average, and deaths due to medical negligence took an average of nine months longer. Deaths due to natural causes closed the fastest, and deaths due to drowning, falls and suicide also closed relatively quickly, with only 6% to 7% of those still open after four years.
