This submission is to the NSW Attorney General’s statutory review of the Coroners Act 2009 (NSW). Based on PIAC’s expertise in the operation of the 2009 Act, developed through its representation of families of the deceased, this submission makes a number of recommendations to improve the coronial system. These recommendations aim to ensure the procedures under the Act positively impact, as much as possible, families of the deceased and operate to the benefit of the wider public by identifying and promoting systemic change to prevent avoidable deaths in future. Recommendations include : clarifying and strengthening the coroner’s role in prevention; ensuring that governments listen and respond to the recommendations of coroners; requiring an independent investigation of deaths in custody or deaths caused by police action; and providing for legal representation of families at inquests.
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