United by the tragic deaths of their sons and inquests that followed, three Canberra mothers have called for reforms and a long-overdue resources boost for the ACT's coronial system.
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Ann Finlay, Ros Williams and Eunice Jolliffe each lost their sons in tragic circumstances in the past decade, leading to three coronial inquests, each ranging from five to seven years long.
For several months, the trio has been lobbying territory politicians to address what they believe is an "unnecessarily adversarial approach" in inquests; provide extra support for families undergoing inquests and to fund a dedicated coroner for the court.
As prosecutors and the court struggle to deal with the ACT's growing criminal case load, such cases, which often involve people in custody, take priority over the Coroner's Court.
It is the only coronial court in the country without the oversight of a dedicated coroner; a critical part of the legal system that has long sat at the bottom of politicians' priority lists.
Ann Finlay waited almost seven years before the inquest into the death of her son, Paul Fennessy, was completed - illustrating the sometimes shocking delays in the court.
"You want to get on with your life, why would we go through all of this, trying to lobby for change, meeting with politicians, writing letters, if we didn't see the need for system changes?" she said.
The others, Ros and Eunice, whose sons struggled with mental health problems for years before their deaths, faced five long years of the same.
"We are lobbying for change to help prevent similar deaths by suicide or mental health in the future," Eunice said.
"We're only three people, three families, that went through the inquest process, but there are more cases out there, and hundreds that never even get to a hearing," Eunice said.
The coronial reform group has urged Attorney-General Gordon Ramsay and Chief Magistrate Lorraine Walker, who also holds the role of Chief Coroner, to provide more resources to families going through inquests, including extra court staff to manage cases and financial support to cover families' legal costs.
"The system as it currently operates is unjust and inequitable," Ros said.
"My son died in 2010, and they said in the inquest, oh, that things were different now, things have changed, and I know some things may have changed, but I know the mental health system in the ACT is dysfunctional still and there are people dying as a result of poor care," Ros said.
"In my son's case, he was on a PTO (psychiatric treatment order), so technically his death was a death in custody, so it had to go to a full inquest, but there's no financial support for families to pay those costs."
While government departments are represented by the government-solicitor and often other high level solicitors, Ros said it cost her family more than $35,000 to hire lawyers for the inquest into her son's death.
"The taxpayer is paying for these lawyers to represent the government, and we're paying for our own lawyers, so really we're paying twice," she said.
While Chief Magistrate Walker has called for extra government funding to pay for a dedicated coroner for several years, the court's latest annual report showed it had "not received a formal response from government" on the issue.
In mid-2015, the government funded a legal manager, who often also acts as Counsel Assisting the Coroner, to the Court, which has seen improvements; but Chief Magistrate Walker continues to push for the dedicated coroner position.
A dedicated Chief Coroner would allow greater high-level oversight of the ACT's coronial system, as well as a deeper focus on identifying systemic issues in the community to help prevent future deaths.
Only 16 of the 291 "reportable deaths" in 2015-16 went to a hearing, and the mothers remain concerned a lack of resources for the court may see some cases dismissed without hearings, despite possibly warranting further investigation.
"We understand some families might not want an inquest, but hundreds of other cases are not investigated, so the facts don't even become public knowledge and we don't know what else our system could have learnt from them," Eunice said.
Attorney-General Gordon Ramsay said the coronial reform group had made a series of recommendations to the government, which would "consider them in detail and respond properly this year".
But he also said Chief Magistrate Walker already had the ability to appoint a chief coroner, and the government had two special magistrates appointed in 2017-18. One was supported by the court "on the basis of their ability to assist with coronial matters".
"The government is continuing to examine the resourcing of the Magistrates Court overall as part of the budget process for 2018-19, as part of a comprehensive examination of resourcing across the justice system," he said.
>Listen to the five-part podcast examining Paul Fennessy's life and death, Losing Paul, here.
Do you know more? Email: daniel.burdon@fairfaxmedia.com.au
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