Coroners' perspectives on deaths in custody in Australia

Australian coroners have several functions in death in custody investigations – they fulfil judicial, pastoral, preventative and data collection roles. We interviewed six coroners from three Australian states to investigate coroners' perspectives on current issues in deaths in custody. In this paper, we present the results of our research on three key areas of interest: Indigenous deaths in custody; recommendations that are commonly made but not implemented; and the role of the coronial process in death in custody investigations. Our sample size was small, however the coroners we interviewed provided some important insights on these issues. A key finding of this research is that official statistics on the number and rate of Indigenous deaths in custody may be inaccurate. Coroners expressed particular concern about the adequacy of mental health care of people in custody, and they were supportive of alternative approaches to death investigations that involved restorative approaches.