'Our system should be stepping up': Why coronial reform is so important

In a TEDx Talk, the US man told the story of going to a hospital, full of excitement, to see a new MRI machine in action after working on its design for more than two years.

But when he saw a terrified little girl having to be comforted by her parents on the way in for a scan, he realised the machines were anything but exciting for children, many of whom had to be sedated to get through the experience.

So Mr Dietz that for the sake of the people using his creations, things had to change.

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Everyone involved reaped the benefits.

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It's this sort of strategy that Canberra-based restorative practitioner Rhian Williams uses as an example when she talks about how to transform the ACT's maligned coronial system and make it fit the needs of the people it is supposed to serve, rather than the other way around.

"At the moment, we have a coronial system that is basically designed to meet legal needs, but a family that has experienced the death of a loved one has a bunch of different needs and is asked to fit themselves within the coronial system," she said.

"The challenge, particularly given Canberra wants to become a restorative city, is how do we build this system so it is more humane for everyone?

"When families are vulnerable and experiencing devastating grief, that's a point where our system should be stepping up and meeting them instead of requiring them to accommodate themselves within the system."

Ms Williams said at present, there was a tendency for coronial proceedings to become adversarial, particularly where government agencies or large organisations were involved in a person's death and moved to "lawyer up" because they were worried about being found liable for the death in subsequent court proceedings.

This created a power imbalance where their legal representation far outweighed that of a grieving family that wanted to ensure their loved one had not died in vain and that the situation wouldn't repeat itself for another family.

Ms Williams, a dispute management consultant, said in building restorative processes, governments needed to find ways of surrendering power - or "lawyering down" - to work together with the people affected.

"It's like dancing," she said.

"At the moment the government is dancing with itself, and we all know how gawky and awkward that looks.

"What [restorative practice] is about is how government and citizens can dance together.

"But it's no good just to do it without the right things in place because you just end up standing on each other's toes, kicking them in the shins and storming off angrily."

As revealed by the Sunday Canberra Times, the ACT government wants to incorporate restorative practices in the coronial system.

It is considering nine coronial reforms, including adopting a restorative approach that would focus on bringing everyone involved in a death together to work collaboratively, rather than in opposition, in an effort to determine what happened and prevent a repeat that resulted in future deaths.

Some of the proposed measures designed to achieve this include introducing a family liaison officer to the ACT Coroners Court, and providing families with opportunities for their wishes to be heard during coronial proceedings.

Families have been at the forefront of calls for change, with the Coronial Reform Group leading the charge in the past five years.

The group is comprised of Canberra mothers Rosslyn Williams, Ann Finlay and Eunice Jolliffe, who each went through the coronial process after the death of a son.

They recently told a coronial reform forum they found the process they experienced "disempowering, re-traumatising and ultimately ineffective".

The trio was determined that families who found themselves going through a coronial inquest in the future would instead emerge from it feeling their voices had been fairly heard, and that systemic failings had been identified in a timely way so other lives could be saved.

They have attended inquests, supported several grieving families including some referred to them by the courts, and advocated for change.

Rosslyn Williams said every family the group had spoken to had one thing in common.

"No one has said they've had a positive experience with the coronial process," she said.

The Coronial Reform Group is keen to see the proposed restorative approach to coronial inquests adopted, with Rosslyn Williams saying the families they had interacted with were most concerned with seeing positive change come from their loved one's death.

These families were generally not litigious and just wanted to see some accountability and lessons learned.

"What families need is to know that the events that have led to the death won't happen to anyone else," she said.

She said another of the government's proposed reforms, which involves creating an online register of published coronial reports and government responses to issues of public safety identified in those reports, would help address a "wilderness" that many families found themselves in even after the coronial process concluded.

At present, while coroners often make recommendations in the wake of a death, there is no simple process in place to allow families to find out whether these were ever implemented or even considered.

Hugh Dillon, a former NSW deputy state coroner, is firmly in favour of using restorative practices in coronial settings.

He encouraged the ACT government, when looking at reforms to the Coroners Act, to re-frame the legislation so its key purposes were preventing future deaths and providing for justice and the needs of grieving families.

"If you can do that, everything else seems to follow from that," Mr Dillon said.

"Your processes are driven by those principles.

"I also think there are benefits to government in adopting restorative processes.

"They can be quicker, they can be cheaper and they can create trusting relationships between the coroners court, government agencies and grieving families in ways that formal inquests can't."

Winnunga Nimmityjah Aboriginal Health Service chief executive Julie Tongs is another advocate for coronial reform, expressing a desire for families to be placed on a level playing field.

She said the current system was "out of balance".

This was particularly clear, Ms Tongs said, after the death of Aboriginal man Steven Freeman in the Alexander Maconochie Centre.

She said the ACT government and the prison doctor's legal representation far outweighed that of Mr Freeman's family, which was represented by a lawyer doing pro-bono work.

"The same legal resources that the government gets should be offered to the family," Ms Tongs said.

"[The government] has got an abundance of money to throw at these cases, and the families have to rely on pro-bono [lawyers], or Legal Aid. Where's the justice in that?"