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The men who weigh death


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Shining a light on child neglect, horror road crashes and shocking domestic violence are all in a day’s work for South Australia’s Coroner and his deputy – they tell InDaily why public attention is crucial to their work.

State Coroner Mark Johns and Deputy Coroner Tony Schapel are charged with investigating any sudden, unexpected or unknown cause of death in South Australia.

“It’s the measure of a decent humane society,” says Johns. “Every death requires an explanation.”

Yet what is uncovered can often reveal itself to be inhumane and unthinkable for many of us. The response to the ongoing inquest into the death of four-year-old Chloe Valentine is just one example, in a year of particularly troubling Coronial inquiries.

Clearly the job of the Coroner is not for the fainthearted and when pressed on how Johns maintains his faith in society he prefers not to answer. However, Schapel acknowledges its impact.

“I do think you absorb a lot of the negative stuff you come in to contact with, it’s a lot of stuff you do think about after hours,” answers Schapel. “But you cope. Mark and I have been doing this job now for eight, nine years. I think we’ve been able to remain reasonably objective and sane throughout this period.

“We live in a decent society that values human life and so long as the systems are in place that we ensure that remains the case, then we take some considerable comfort in that knowledge.”

Last year there were 2,248 reportable deaths to the Coroner’s Court and only 32 of them went to an inquest. There were 36 inquests still waiting to be heard with 27 involving a death in custody.

In all there were still 1,878 open cases pending inquiry or at some level of investigation. And with budget cuts rolling out across the judiciary, the Coroner’s Court has not been spared.

In his recent report to state Parliament, Johns said: “With impending significant budget cuts I cannot promise a service that continues as it has done in previous years… Should we suffer further staff and budget cuts then I cannot say with any assurance that we will be in a position to maintain reasonable timeframes for completion of matters, or of dealing with the myriad of enquiries and correspondence we receive each week.“

On average any reportable death could take anywhere from nine months to two years to investigate. Yet as we saw with the fatal accident off the South Eastern Freeway a few months ago, families and experts can be called in to an inquest within days.

“Families and the bereaved tend to cope better with a coronial inquest after a period of time,” says Schapel. “Now some might say that it’s desirable for an inquest to be heard the sooner the better but it is just my impression that an inquest taking place while the grieving process is very acute is sometimes not all that helpful.

“That’s not say that we will not convene a quick inquest if the circumstances in our opinion demand it.”

Johns and Schapel stress they are both committed to uncovering the cause of each reportable death.

“Tony and I ultimately look at every single one of those files, those 2,000 files in a year,” says Johns. “There is a process of review and further review and further review where you say we have now reached a point where we can say that we’re confident that this case has been investigated adequately and it is not a case where we think it will need to be the subject of an inquest.”

“Our task is to find facts,” says Schapel. “That’s not to say where there has been a departure from proper practice or a departure say from established poles of standards that we will not say so and say so robustly. But I think it’s possibly out there that we have a responsibility to cast blame and possibly to cast it in circumstances where it may not necessarily need to be cast.”

“The fact is there are still a group a people who will never be satisfied until a particular person they think is responsible is pinned up against the wall,” adds Johns. “Really there is just nothing we can do in those kinds of cases beyond what we’ve done by way of investigation.”

The Coroners do not have the power to lay criminal charges and Johns says that is one of the common public misconceptions about the court. What they can do is make recommendations to the government and sectors of our community to prevent any further deaths. However, not all recommendations will be heeded.

“We’ve got no power to require that our recommendations are implemented and I’m not saying that I think we should have such a power either,” explains Johns. “The force of what we find and what we recommend is in the public reaction to it, and the public only knows about it generally through the media.”

Recently inquests in to the deaths of Zahra Abrahimzadeh, who was murdered by her husband, and Chloe Valentine have done just that. Yet not all cases that go to an inquest receive this kind of extensive media coverage – and scrutiny.

“There is no doubt that probably the coronial jurisdiction more than any other needs the media’s interest to make it as effective as it can be,” says Johns.

“Sometimes I am surprised to see no media interest at all in a particular case where I have thought it would be of interest to the media. I think it is a matter of media resources and reporters perhaps.”

While a death in custody may not attract a lot of media attention, the fact that the Coroners’ repeated recommendations are not being acted on perhaps should.

“There’s been tens of inquests where recommendations have been made about improving prison cells so that hanging points are eliminated as much as possible and over the years the response has been that it’s unaffordable,” says Johns.

“I think there have even been times when the same cell has actually featured.”

“Or at least the same cell block,” according to Schapel. “Death in custody inquests, which are mandatory, draw attention to the fact that coronial recommendations have been made in the past and frequently made in the past – that ligature points in cells ought to be eliminated.”

“And consistent with the recommendations of the Royal Commission into Aboriginal Deaths in Custody in the late 80s early 90s, in the last century,” adds Johns.

The Coroner’s Court places under the microscope legislation, government, businesses and agencies. Just this year we have seen the court scrutinise mental health care for adolescents, SAPOL’s response to domestic violence, the treatment of prisoners with serious illness and the safety of procedures in some private hospitals.

“What we do is done totally independently and done without fear or favour,” says Johns.

It is that independence that can not only assist with creating change but also bring comfort to loved ones.

While not every death will receive the scrutiny of an inquest or the intense glare of the media, there is a reassurance that the dedicated team behind the Coroner’s Court is examining it.

“From the receptionist right through, (our staff) will have to deal with some distressed people and some very distressing phone calls and they do it really really well,” says Johns.


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