For more than three decades, Victorian coroners have investigated deaths in custody and returned findings that share a striking family resemblance: inadequate medical care, failures in duty-of-care monitoring, systemic gaps in the management of people with mental illness, and the persistent, disproportionate toll on Aboriginal and Torres Strait Islander people. Yet the recommendations attached to those findings are repeated, year after year, because the underlying conditions that produced them have not been resolved.
This is not a failure of the coronial system. It is a stress test that the system keeps running — and that governments keep deferring.
What a coronial inquest actually does #
When a person dies in custody in Victoria — whether in a prison, a police cell, a youth justice centre, or in the process of being detained — the Coroners Court of Victoria has mandatory jurisdiction to investigate. The coroner’s role is not to assign criminal or civil liability but to establish the medical cause of death, the circumstances surrounding it, and whether systemic changes could prevent future deaths.
Findings are public documents. Recommendations can be directed at government departments, Corrections Victoria, Victoria Police, the Department of Health, or any agency the coroner believes has the capacity to act. Crucially, however, agencies are not legally compelled to implement those recommendations — they are required only to respond, stating whether they accept, partially accept, or reject each finding. Implementation is discretionary.
That gap between recommendation and implementation is at the heart of the recurring pattern.
What the findings keep saying #
A review of Victorian coronial findings over the past decade reveals several themes that appear with such regularity they have become, in the words of one submission to the Yoorrook Justice Commission, “a literature of unacted-upon grief”.
- Inadequate health screening on reception. Coroners have repeatedly found that people — particularly those with substance dependency or mental illness — were not properly assessed when they entered custody. Pre-existing conditions went undetected or were not communicated across shifts.
- Failures in welfare monitoring. A number of findings have identified that required cell checks were not completed at the required intervals, or were completed in form only — a brief visual inspection rather than a meaningful welfare assessment.
- Delays in emergency medical response. Findings have documented cases where custodial staff were slow to recognise medical emergencies or to escalate to emergency services, and where the transfer of a person to hospital was delayed.
- Inadequate mental health support. Coroners have consistently found that mental health services inside Victorian correctional facilities are under-resourced relative to the high rates of mental illness in the custodial population.
- Systemic disadvantage as a precursor. Across nearly every inquest involving an Aboriginal or Torres Strait Islander person, findings acknowledge the direct link between that person’s death and the downstream consequences of colonisation, intergenerational trauma, removal from family, and economic marginalisation — noting that incarceration itself was often a product of those circumstances, not simply of individual conduct.
The Aboriginal death toll — a distinct and urgent pattern #
Aboriginal and Torres Strait Islander people are profoundly over-represented in Victoria’s custody population. While making up roughly 0.8 per cent of Victoria’s general population, Aboriginal people account for a significantly higher proportion of deaths in custody — a disparity that has not narrowed in any sustained way since the Royal Commission into Aboriginal Deaths in Custody handed down its final report in 1991.
That royal commission made 339 recommendations. Advocates and community organisations — including the Victorian Aboriginal Legal Service and the First Peoples’ Assembly of Victoria — have documented repeatedly that many of those recommendations remain only partially implemented, or not implemented at all, more than 30 years later.
Victorian coroners investigating the deaths of Aboriginal people in custody have in recent years expressly referenced this history. Several findings have named the failure to implement royal commission recommendations as a contributing systemic factor — a forensic acknowledgement that these are not isolated tragedies but the foreseeable consequences of sustained policy failure.
Families of those who have died have described the inquest process to VCN as simultaneously necessary and exhausting — a formal mechanism that gives them answers about how their loved one died, but that cannot compel the changes that might mean the next family does not face the same process.
Yoorrook and the accountability overlay #
The Yoorrook Justice Commission — Victoria’s truth-telling body established under the Yoo-rrook Justice Commission Act 2021 — has heard extensive evidence about deaths in custody as part of its examination of the impact of colonial laws, policies, and practices on First Peoples in Victoria.
Yoorrook operates differently from a coronial inquest. Its mandate is structural and historical: it is examining patterns across institutions, not the circumstances of a single death. It has the power to compel the production of government documents and to take evidence under oath, and its findings — due before the commission’s work concludes — are expected to address deaths in custody as part of a broader set of recommendations on justice and policing.
Advocates have told Yoorrook that the coronial system, while valuable, is not designed to function as a systemic accountability mechanism on its own. The commission has heard evidence suggesting that government agencies sometimes treat coronial recommendations as a compliance exercise rather than a genuine reform mandate — providing formal responses without meaningful follow-through.
What Yoorrook may add is political and moral weight that the coronial system cannot generate alone: a public, truth-based record of institutional failure directed specifically at the Victorian government, with treaty negotiations as the broader accountability framework.
The government response track record #
The Victorian Government publishes responses to coronial recommendations through the relevant responsible ministers. VCN’s review of publicly available responses over the past five years shows a pattern in which agencies frequently accept recommendations in principle but provide timelines that are vague, or describe existing programs as responsive to new recommendations without demonstrating that those programs are calibrated to the specific findings.
The Victorian Inspectorate and the Office of the Chief Psychiatrist have oversight roles that bear on conditions in custody, and both have produced reports that echo coronial findings on mental health and duty-of-care failings. The accumulation of consistent findings across multiple oversight bodies — coroners, inspectors, parliamentary committees — makes it increasingly difficult to characterise the gaps as unknown or unforeseen.
The Victorian Government has, since 2016, committed to a number of justice-reinvestment and self-determination initiatives in partnership with Aboriginal communities, including the Woor-Dungin program and various custodial throughcare models. Community organisations and some coroners have acknowledged these as positive steps. However, advocates have argued consistently that the pace and scale of implementation is not commensurate with the urgency of the problem.
What accountability could look like #
Legal and community advocates who have spoken to VCN over the course of our courts and justice coverage identify several structural changes that would move the dial beyond the current cycle of findings and deferred recommendations.
These include a mandatory and publicly reported implementation-tracking mechanism for coronial recommendations — one with independent oversight rather than self-reporting by the agencies named. They also include fully resourcing Aboriginal-controlled organisations to provide throughcare, community supervision, and diversion services at a scale that meaningfully reduces the rate at which Aboriginal people enter and re-enter custody in the first place.
Advocates also point to the broader conditions that produce the overrepresentation: the over-policing of public space in communities with high Aboriginal populations, the criminalisation of public drunkenness (only recently reformed in Victoria), the lack of culturally safe mental health services, and housing instability. Each of these is a coronial recommendation waiting to be made — or, in most cases, one that has already been made and is waiting to be acted upon.
The Coroners Court of Victoria can tell us how people died and what might have prevented their deaths. What it cannot do is make governments act. That responsibility belongs to the institutions that keep receiving the findings — and to the public that elects them.
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- 13YARN — crisis support for Aboriginal and Torres Strait Islander peoples: 13 92 76
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- Beyond Blue — mental health support: 1300 22 4636
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