Most Victorians only hear about the Coroners Court when a high-profile death makes the news — a workplace accident, a death in custody, a child fatality that shocks a community. What gets far less attention is what happens after the finding: a system of recommendations, responses and follow-up that makes Victoria’s coronial jurisdiction one of the most prevention-focused in the world.
This is a plain-English guide to how that system works, why it matters, and what it means when the court tells a government agency — including Victoria Police — to change the way it operates.
What the Coroners Court actually does #
The Coroners Court of Victoria is established under the Coroners Act 2008 (Vic). It is a specialist statutory court, not a criminal court, and its purpose is fundamentally different. Rather than determining guilt or innocence, the court investigates the circumstances of reportable deaths and fires — and, critically, asks what can be done to prevent similar deaths in the future.
A coroner can investigate any death that is unexpected, unnatural, violent, or where the cause is unknown. Deaths in custody — including police custody, prison, and approved mental-health facilities — are always reportable. The court also has jurisdiction over certain serious fires.
At the conclusion of an investigation, a coroner makes a finding: a formal document that sets out, on the balance of probabilities, the identity of the deceased, the cause of death, and the circumstances in which the death occurred. Importantly, a finding is not a criminal conviction. The court cannot find that a person is criminally responsible for a death — that is the role of the criminal courts. What it can do is make comments and recommendations directed at reducing the likelihood of similar deaths happening again.
Mandatory inquests: when a hearing is required by law #
Not every reportable death proceeds to a full inquest. Many are resolved through a streamlined investigation, particularly where the cause of death is clear and there are no systemic concerns. But the Coroners Act mandates an inquest in specific categories of death where the public interest in scrutiny is highest.
Mandatory inquests are required for:
- Deaths of people in custody or care — including deaths in police custody, prison, youth justice, and approved mental-health facilities;
- Deaths of children who were known to child protection services at the time of, or in the two years before, their death;
- Deaths where the coroner believes an inquest is necessary to find out the cause, or to make recommendations.
An inquest is a public hearing. Witnesses give evidence under oath, legal counsel can appear for families and interested parties, and the proceedings are on the public record. Families of the deceased have a right to participate — a recognition that coronial proceedings serve not just the public interest but the personal need for accountability and answers.
The Prevention Unit: where findings become action #
In 2015, the Coroners Court established its Prevention Unit — a dedicated team that sits within the court and whose sole focus is ensuring coronial recommendations lead to real-world change. This is what sets Victoria apart from many comparable jurisdictions.
The Prevention Unit monitors whether the agencies and organisations named in recommendations actually respond — and respond meaningfully. Under the Coroners Act, any organisation that receives a coronial recommendation is legally required to respond in writing within three months, outlining what action it has taken or intends to take, or explaining why it does not intend to act on the recommendation.
That obligation is not optional. A coroner can refer a failure to respond to the Attorney-General. The Prevention Unit tracks responses, follows up where replies are inadequate, and publishes data on compliance rates. As of recent reporting years, response rates from government agencies have been high — but the quality and substance of those responses varies considerably, and the unit’s scrutiny role is ongoing.
The unit also identifies patterns across multiple deaths — for example, clustering of suicides near a particular location, or repeated failures in medication management in aged-care settings — and brings those patterns to the attention of the relevant coroner and policymakers. This systemic lens is central to the prevention mandate.
How Victoria Police is required to respond #
Victoria Police is among the most frequently named respondents to coronial recommendations, for two primary reasons: the force investigates many of the deaths that come before the court, and deaths in police custody trigger a mandatory inquest.
When a coroner directs a recommendation to Victoria Police, the force must provide a formal written response within the statutory three-month timeframe. That response becomes part of the public record. In practice, Victoria Police maintains an internal governance process for managing coronial recommendations — a dedicated team within the organisation reviews findings, coordinates responses across relevant commands, and tracks implementation.
Recommendations directed at Victoria Police have historically covered a wide range of operational and policy matters: the use of force, mental-health co-responder models, welfare checks, in-custody care obligations, pursuit policies, and the handling of family violence callouts. Where a coroner finds that a systemic failure contributed to a death, the recommendation may require the force to review a specific policy, introduce new training, or change an operational procedure.
It is important to understand what a coronial recommendation is — and is not. A recommendation is not a finding of fault in the criminal or civil law sense. It does not constitute a finding that any individual officer or the force as an institution acted unlawfully. Families and advocates sometimes find this distinction difficult, and it is a legitimate tension within the system. What the recommendation framework provides is a mechanism for institutional learning — a public, documented requirement to consider change — rather than a punitive outcome.
Recent areas of focus #
Over recent years, the Coroners Court’s prevention work has concentrated on several areas that reflect broader public health and safety concerns across Victoria.
Mental-health related deaths — including suicides — account for a significant portion of the court’s workload. The court applies strict Mindframe-aligned protocols to how such deaths are reported and discussed publicly, and recommendations in this space frequently address gaps in crisis services, transition care, and community follow-up.
Deaths on Victorian roads, particularly in regional areas, have generated a substantial body of coronial recommendations directed at the Department of Transport and Planning, VicRoads predecessors, and local councils — covering everything from road surface conditions to speed limits near schools.
Deaths in aged care and disability settings have attracted growing attention, with recommendations touching on medication management, restraint practices, staffing ratios, and the obligations of approved providers under Commonwealth and state frameworks.
First Nations deaths in custody remain a profound and unresolved area of concern, consistent with the findings of the 1991 Royal Commission into Aboriginal Deaths in Custody. Victoria’s coroners have made extensive recommendations in this space, and community advocates continue to monitor whether those recommendations translate into genuine systemic change.
Where to find coronial findings #
All coronial findings are published on the Coroners Court of Victoria website, fully searchable by name, date, and subject matter. The Prevention Unit’s annual data on recommendation responses is also publicly available. For journalists, researchers, legal practitioners, and families seeking to understand a finding or track an agency’s response, the court’s public registry is the starting point.
VCN will continue to cover significant coronial findings and prevention outcomes as part of our courts reporting. If you have information about a coronial matter you believe warrants public scrutiny, our newsroom can be contacted securely.
Support services #
If anything in this article has raised concerns for you or someone you know, free and confidential support is available around the clock.
- Lifeline — crisis support and suicide prevention: 13 11 14
- Beyond Blue — mental health support: 1300 22 4636
- 13YARN — crisis support for Aboriginal and Torres Strait Islander peoples: 13 92 76
- 1800RESPECT — family violence and sexual assault counselling: 1800 737 732
- Safe Steps — family violence response, Victoria: 1800 015 188
- Sexual Assault Crisis Line — Victoria: 1800 806 292
- Crime Stoppers — report information to police: 1800 333 000
