Reading 463 coronial
reports, Guardian Australia found a record of systemic failure.
She said Te Runanga supported the amendment change "but want them to go further", with cultural competency training for all frontline staff across the coronial
and health sectors.
I will be asking if the coronial
system works for the victims and the bereaved or is actually on the side of others, because I think it's been a pretty depressing journey these past two years.
* Australian Coronial
data highlighted the lack of standards that result in disparity between what the coroner is legally required to document and what is needed to inform suicide prevention programs in the community (Dodds et al.
inquest examining the circumstances heard on Thursday, the public prosecutor who decided not to oppose Monis' bail two months before the Sydney Siege had only been on the job for two months.
The article goes on to examine the offences and penalties that attach to a failure to comply with coronial
The report also looked at the use of coronial
files in investigations of perioperative mortality, and confirmed the important place of this information in understanding surgical deaths.
"It is clearly in the interest of the general public that they should be able to have confidence in the coronial
system and this confidence has been undermined by your failures in these cases," panel chair Robert Lloyd-Richards said.
Bowen could not comment on the claims of poisoning, saying the cause of death was a matter for police and "no doubt" a coronial
Rachel Cerfontyne, the IPCC commissioner, stressed the need for a full and thorough inquiry: "I also have a responsibility to balance the need to provide information with the need to avoid adversely affecting other judicial and coronial
inquest into the fatal Flinders Islet yacht race accident has found that the deaths of Andrew Short and Sally Gordon were the result of drowning caused by a boating accident.
Previously, one of the authors (KBG) reviewed the coronial
inquest of the death of a patient from acute airway obstruction from Ludwig's angina (5).