wide coronial assistance services 2016-2020. queensland … · final report this report to justice...
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Carpenter, Belinda, Tait, Gordon, Shakespeare-Finch, Jane, Jowett,Stephanie, & Malone, Emma(2020)Justice and Attorney General (JAG) Final report: Evaluation into State
Wide Coronial Assistance Services 2016-2020.Queensland University of Technology, Australia.
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FINAL REPORT
This report to Justice and Attorney General is based on a completed evaluation into state wide coronial assistance services 2016-2020 (Contract no. DJAG 579.1718).
Professor Belinda Carpenter Queensland University of Technology Professor Gordon Tait Queensland University of Technology Professor Jane Shakespeare-Finch Queensland University of Technology Ms Stephanie Jowett Ms Emma Malone
Table of Contents A. Executive Summary of Thematic Findings of the Evaluation ................................................... 1
B. Key Recommendations: Coronial Legal Assistance Scheme .................................................... 3
C. Further recommendations .................................................................................................... 4
D. Context of the Evaluation ..................................................................................................... 5
E. The Coroner System and families .......................................................................................... 6
F. The Service Providers ............................................................................................................ 7
G. Method. ............................................................................................................................. 10
H. Findings and Discussion: Part 1 ........................................................................................... 15
Interviews with Legal Professionals ............................................................................................ 15
Theme 1: Importance of legal service to support families ............................................................... 15
Theme 2: Positive Interactions with Service Providers: During the Inquest .................................... 17
Theme 2: Positive Interactions with Service Providers – outside the Inquest ................................. 18
Theme 3: Lack of Uniformity in the Referral Process ....................................................................... 20
Theme 5: Who should have access to free legal support ................................................................. 22
Theme 6: Unmet needs within the provision of legal support ......................................................... 24
Theme 7: unmet needs beyond the provision of legal support ....................................................... 25
Conclusions to Part 1 .................................................................................................................... 28
I. Findings and Discussion Part 2 ............................................................................................ 29
Survey of legal and non-legal professionals ................................................................................. 29
Quantitative Results ...................................................................................................................... 29
a) Demographics (Q1, Q2, Q3, Q4) ............................................................................................... 29
b) Awareness of and Access to the Service (Q5, Q6, Q8, Q10, Q11, Q13, Q16) ........................... 29
c) Evaluation of the Service (Q14, Q17, Q18, Q19) ....................................................................... 30
d) Preliminary conclusions ............................................................................................................ 31
Qualitative results ......................................................................................................................... 31
Access to the Coronial Legal Assistance Service (Q7, Q9, Q12) ........................................................ 31
Value added by the service (Q15, Q20, Q21) .................................................................................... 34
Improvements and gaps in the current service (Qs 22, 23) .............................................................. 37
Conclusions to Part 2 .................................................................................................................... 39
J. Discussion and Findings - Part 3 .......................................................................................... 40
Interviews with Family Members ............................................................................................... 40
Theme 1: Access to Legal Support and Range of Services ................................................................ 40
Theme 2: Family Perceptions of the Service Provided ..................................................................... 43
Theme 3: Problems with the coronial process and provision of legal support ................................ 46
Conclusions to Part 3 .................................................................................................................... 51
K. Discussion and Findings - Part 4 .......................................................................................... 53
Survey of Family Members ......................................................................................................... 53
Quantitative results ...................................................................................................................... 53
a) Demographics (Q1, Q2, Q3, Q4, Q5) ......................................................................................... 53
b) Awareness of and Access to the Service (Q6, Q7, Q8, Q9, Q11, Q12, Q14) ............................. 53
c) Evaluation of the Service (Q10, Q15, Q16) ............................................................................... 54
d) Preliminary conclusions ............................................................................................................ 54
Qualitative results ......................................................................................................................... 55
Value provided by the service (Q17)................................................................................................. 55
Improvements and gaps in the current service (Qs 18, 19) .............................................................. 56
Conclusions to Part 4 .................................................................................................................... 60
A. References ......................................................................................................................... 62
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A. Executive Summary of Thematic Findings of the Evaluation
Findings specific to the Evaluation of Legal Services.
• The Coronial Legal Assistance Service is important to support families in the coronial
jurisdiction. Importantly, how the legal advice is offered is as important as the legal
advice itself, with emotional support and compassion rated as key to its effectiveness.
It is also the case that not all families requiring support are gaining access and the
limitations of the support is exacerbating the distress of some families during the
investigation
• Value is added by the Coronial Legal Assistance Service to families but their
expectations of support are not always matched by the provision of legal support
through the Coronial Legal Assistance Service. It is also not as highly regarded by
families as it is by the professionals in the jurisdiction.
• There is a lack of clarity and understanding about the referral process to the Coronial
Legal Assistance Service, with very few of the family members interviewed relying on
a referral to the Coronial Legal Assistance Service. Referrals that do occur are primarily
for support during an inquest which is often only accessed in the weeks preceding the
court process.
• There is poor communication between legal, government and non-government
organisations about the coronial legal assistance service and as a consequence, many
professionals have relied on informal networks or the service providers themselves as
to the existence of the Service, and its mandate.
• With little guidance as to which families should be referred to the Coronial Legal
Assistance Service, and when that referral should occur, professionals with the
coronial jurisdiction appear to be acting as discretionary gate keepers to the service,
referring only those families perceived as in the greatest need. However, family
members indicate that this discretionary referral process does not clearly identifying
those families who do want or need legal support and/or are suffering the greatest
trauma.
• There are difficulties attached to offering probono legal support in the specialised
jurisdiction of the coronial court, especially outside the south east, and this is
exacerbated by the lack of a dedicated contact person attached to each coroner, in
the form of a family liaison officer.
• Families were very aware of the ways in which the low level of funding to the Coronial
Legal Assistance Service was limiting their access to legal support (and justice) and
were frustrated with the delays in communication, and staff changeovers that
occurred as a result. They identified access to Legal Aid, more face to face support in
regional locations and reciprocal relations with other states, as well as legal support
from the beginning of a coronial investigation, as useful additions to the provision of
legal support for families.
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• There is a human cost to the death of a family member and the coronial jurisdiction
can exacerbate that harm. This trauma and harm most often manifested through
suspicion and a lack of trust in the coronial investigation – including at times the
Coronial Legal Assistance Service - and its outcomes.
• The identification of a conflict of interest that precludes ATSILS from representing
more than one Indigenous family in the coronial jurisdiction means that there is a need
for more culturally appropriate legal support beyond ATSILS
Findings related to Coroner’s Court opportunities
• The poor communication between the Coroners Court and other organisations
extends to families who rely on the Coronial Legal Assistance Service due to the little
to no information coming from the Coroner’s Office, their reactive approach to
accessing information and unclear and protracted processes and delays.
• The vulnerability of the families and the traumatic nature of the jurisdiction means
that there is a clear need for counselling/emotional support to families (beyond next
of kin) and witnesses over the life of the investigation. This should also be offered to
staff as required. It is also important that the legal service provision is offered by
emotionally intelligent service providers in an emotionally supportive and
compassionate environment.
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B. Key Recommendations: Coronial Legal Assistance Scheme
1. Funding for the Coronial Legal Assistance Service should be continued and extended if possible. However, this should only occur once the referral process has been formalised, and communication of the Service is clarified and consistent.
2. Clarity over the vulnerability criteria is required. We suggest replacing the Coronial
Assistance Legal Service Guidelines, returning to the National Partnership of Legal Assistance.
3. Clarity over the referral process is required. We suggest a blanket referral process
from the Coroners Court with further discussion as to the most appropriate stage for when a referral should be triggered. We suggest screening occur at the Coronial Legal Assistance Service post referral.
4. Clarity over the range of services provided by the Coronial Legal Assistance Service is
required. We suggest that all families whose loved one is being investigated through the Inquest should be provided with access to independent legal support if they desire it. Families that meet the vulnerability criteria as outlined in the National Partnership of Legal Assistance should have that legal support provided by the Coronial Legal Assistance Service.
5. Disbursements should be provided to cover the travel and accommodation costs of
lawyers and barristers providing legal assistance at the Inquest through the Coronial Legal Assistance Service. This should not have to be provided by the families.
6. The Coronial Legal Assistance Service should be provided in more regional areas,
ideally in each location where a Coroner is currently based.
7. Inter-state relations between legal assistance schemes and the coroners court should be explored.
8. The role of Legal Aid in providing support for families should be further explored.
9. Barristers working probono in the inquest through the Coronial Legal Assistance
Service should have the opportunity for training to increase their skills in this specialised jurisdiction.
10. The utilisation of the Coronial Legal Assistance Service by other organisations needs
to be considered in light of funding agreements and legislative requirements. We suggest clear communication between organisations about the focus and capacity of the Coronial Legal Assistance Service is required, as well as referral pathways. Particular focus on the capacity of ATSILS should be explored.
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C. Further recommendations
The following recommendations while beyond the scope of the legal services provision,
should be seen as opportunities for consideration to increase the experience of families
negotiating the coronial jurisdiction.
1. A dedicated family liaison officer should be appointed to each coroner in Queensland to provide familial communication and support and clear referral pathways for families to the Coronial Legal Assistance Service, and to a separate counselling service as required. This position would bring the coronial system in line with other organisations in Queensland such as Office of Industrial Relations, and the clear referral pathways would mean that all families negotiating the coronial system are treated consistently.
2. Counselling support should be extended to include families and witnesses and
continue beyond the immediate impact of the death to include support for the duration of the investigation. Counselling for staff should also be considered in this process.
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D. Context of the Evaluation
The purpose is to report to Justice and Attorney General on a completed evaluation into state
wide coronial assistance services 2016-2020 (Contract no. DJAG 579.1718). As noted in the
tender, the Queensland Government allocates funding for the delivery of legal assistance to
vulnerable and disadvantaged Queenslanders. State wide coronial assistance services are a
new component of Queensland service system, commencing in May 2017, in response to
identified legal need.
The knowledge that legal assistance for families involved in a coronial investigation is an
identified legal need, has since been supported through a Report on Coronial Services 2018-
2019 by the Queensland Audit Office (Worrall 2018). Released in October 2018, the relevant
findings of this report to the current evaluation include the following:
• despite the intent of the Act to support families during a coronial investigation, the
communication and support provided to families is inadequate;
• referral to FSS coronial counsellors is limited to providing information and support to
families at the beginning of a coronial investigation;
• witnesses at inquest often require support and that this is limited;
• many of the system issues identified in the 2002 review of the previous Act (the
Coroners Act 1958) still exist, including a lack of support and information for families.
The relevant recommendations from this audit are also worth noting as follows:
• The appointment of appropriately experienced and trained case managers to
proactively manage investigations and be the point of contact for families;
• Establishment of processes to ensure families receive adequate and timely
information throughout the coronial process;
• Ensuring sufficient counselling services are available and coordinated to support
families and inquest witnesses.
Correspondence from the Project Director, Coronial Services Governance Board, indicates a
commitment by Agencies to implementing all recommendations made by the QAO, including
to improve the supports available to families throughout a coronial investigation, with work
currently underway to progress these reforms. Nevertheless, these findings and
recommendations add weight to the Government’s decision to pilot specific legal assistance
for the increasing number of families brought into the coronial system each year. For
example, in the most recent Annual Report of the Coroners Court of Queensland (2017-2018)
5812 deaths were reported to coroners, an increase of 225 deaths over the 2016-2017
financial year. During this time, the Coroners Court also cleared 5618 matters, which was the
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largest number of matters cleared in the courts history. These deaths do not discriminate,
drawing families into the system from a range of rural, regional and urban areas, social
classes, cultures and religions, and upon notification by police, a range of legal matters must
be negotiated by families who are in the midst of grief, shock and trauma. While the majority
of families might only need comprehensive legal support in the first week of a coronial
investigation, after which the body is released and the funeral can occur, some families
require ongoing legal support if for example, the death of their loved one is subject to an
inquest investigation.
With an increasing population in Queensland, more deaths will come under the purview of
the coronial system. How Governments respond to ensure appropriate and timely legal
support to enable all families to navigate their way through the legal processes at a time when
they are very vulnerable will test human and material resources. What is clear is that
appropriate resourcing or a lack of it needs to be supported through an evidence-based
approach.
E. The Coroner System and families
Since 1985 in Australia, all state jurisdictions have undertaken major reviews of their coronial
systems. The last to overhaul their Coroners Act was Queensland which replaced The
Coroners Act (1958) with The Coroners Act (2003). Following the precedence set by the other
States, and with a capacity to reflect on the previous changes, the central features of the
Queensland coronial system is to emphasise: the desirability of a more consistent, efficient
and transparent coronial system; the right of family members to be involved in coronial
investigations; and, the need for coroners to seek to contribute proactively to a safer and
more just community (State Coroners Guidelines 2013: chp1).
It is the second of these that offers a focus for discussion in the report. Prior to the
introduction of the Coroners Act 2003, family members were treated as observers in a death
investigation, with no right to participate in decisions about their deceased relatives. The
inclusion of families in the Coroners Act 2003, gives them the right to:
• have their views considered when issues arise such as the extent of autopsy, and to
be informed of the coroner’s decision to retain organs/tissues for further investigation
(State Coroners Guideline’s 2013: chp 2.3);
• adequate and timely information about their loved ones death (State Coroners
Guideline’s 2013: chp 2.4, 2.9), a recognition that delays in finalising coronial
investigations can exacerbate a families suffering (State Coroners Guideline’s 2013:
chp 2.7), and that coroners should carefully consider any known family concerns
before they finalise their investigation (State Coroners Guideline’s 2013, chp 2.8);
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• make application for an inquest and review of reportable death or inquest decisions
or findings (State Coroners Guideline’s 2013, chp 2.10), be notified of a coroners intent
to hold an inquest and have access to the brief of evidence regardless of their role in
the inquest (State Coroners Guideline’s 2013, chp 2.11), and a right to receive findings
and comments (State Coroners Guideline’s 2013, chp 2.12).
The little research there is on families dealing with a coronial death suggest that coronial
processes can cause further trauma to family members already suffering significant grief
(Harwood et al 2002). This has been noted in particular during the inquest (Alison Chapple,
Ziebland and Hawton 2012; Biddle 2003), in the scandals relating to the retention of organs
(Drayton 2011) and experimentation on bodies (Walker 2001), and in the commonplace (and
legislative necessity) of autopsy, where terms such as ‘mutilation’, ‘desecration’, and ‘barbaric
acts’ have been used by families to describe images of the autopsy of their loved one (Robb
and Sullivan 2004:41). This trauma and distress is exacerbated by delays in finalising coronial
matters. As of June 2018, of the 2113 matters pending, 18.4 percent of these were more than
24 months old (Annual Report 2017-2018). While this can be partly explained by the
increasing complexity of the deaths under investigation, it is not helped by the increasing
delay in issuing autopsy reports which were estimated to take pathologists 4 months on
average (Qld Audit Office 2018).
F. The Service Providers
The Queensland Government has allocated $325 000.00 (2017-2020) to deliver legal services
to grieving families experiencing a coronial inquest. This money was allocated to Caxton Legal
Centre (hereafter “Caxton”) to fund the equivalent of 0.9 FTE and to Townsville Community
Legal Centre (hereafter “Townsville”) to fund 0.1 FTE. The evaluation team engaged the
service providers from the beginning of the evaluation in a range of ways:
• to access data and documents
• to seek input into the stakeholders to be interviewed and surveyed
• to understand the strengths and weaknesses of the service from their perspective
In the course of these discussions it was confirmed that the eligibility to access the service
has been relaxed for the purpose of the pilot, from what is strictly required under client
eligibility under the National Partnership Agreement of Legal Assistance Services. The
eligibility for the program is detailed in the Coronial Assistance Legal Service Guideline. While
this maintains a priority to clients who meet the National Partnership Agreement financial
disadvantage indicators, it does not preclude Caxton and Townsville providing legal advice
and support to clients outside of those parameters. This is based on the argument that
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“vulnerability is a far broader concept than simple financial vulnerability” (service provider 3).
This modification to the guidelines was accepted by the State Government for the pilot.
Information provided by Caxton and Townsville demonstrates the consequence of this
modification through the demographics of those who have accessed coronial legal assistance,
which includes 4 families with no income; 38 assessed as low income, 18 assessed as medium
income and 3 assessed as high income families.
While the tender suggests that there be a focus on families experiencing a coronial inquest,
data supplied by Caxton and Townsville details a range of support offered by Coronial
Assistance Legal Services beyond inquest support. As of March 2019, 94 families had received
either casework assistance or discrete legal assistance in the form of legal advice and legal
tasks. This includes appearing on behalf of clients in 12 inquests, and supporting a further six
families during inquests by preparing pleadings and statements, attending pre-inquest
conferences, and making submissions pre and post inquest. Outside of inquests, discrete
legal assistance can range from simple one off advice to more complex legal tasks spanning
several days. The most common complex tasks are requests for documents and information,
support during an inquest, and explanations of the coronial process. Other matters include
contested burials, requests for inquests and review of the Coroner’s decision. Caxton Legal
Centre’s social worker had also provided social work support to 18 clients. Townsville does
not have this support service available.
The coroners court website does direct families requiring support to the Coronial Family
Services, which provides skilled counsellors to relatives and friends.
(https://www.courts.qld.gov.au/courts/coroners-court/support-for-families). However, with
only five counsellors employed for the entire state, this service is generally only able to
provide information and support at the beginning of the coronial investigation, and prior to
the body being released (Qld Audit Office 2018). This same site also provides information
about the Coronial Legal Assistance Service, with links to both Caxton and Townsville, as well
as to a range of other legal advice including Legal Aid, Queensland Law Society, Community
Legal Centres Queensland and LawRight.
In terms of communicating legal assistance to families via direct contact with families during
a coronial investigation, correspondence supplied by the Coroners Office, ATSILS and Office
of Industrial Relations, indicates that families are differently apprised of their access to this
or other legal support. For example, in the first letter to a family whose loved one is being
investigated by the coroner, information is provided by the Queensland Courts about Coronial
Family Services but not Coronial Assistance Legal Service. Similarly, when a family is being
informed by the coroner that an inquest is to be held into the death of their loved one,
Counsel Assisting is offered for a pre-inquest hearing and the Court Network for support
during the inquest. The Coronial Assistance Legal Service is not mentioned.
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In contrast, if the family has been identified as Aboriginal or Torres Strait Islander, the
notification of an inquest letter contains the following: “As previously advised, we have
written to ATSILS. They may be able to assist you with legal representation, if you wish”. This
request for ATSILS to engage with each Aboriginal and Torres Strait Islander family pulled into
the coronial system came directly from ATSILS to the inaugural State Coroner Michael Barnes
in 2010. Similarly, families who have lost a loved one through a workplace accident are
directed to Coronial Assistance Legal service via the Work Safe website at:
https://www.worksafe.qld.gov.au/about-us/consultative-committee. We are advised
through correspondence with the Office of Industrial Relations that staff talk about the
Coronial Legal Assistance Service in conversations with family when they are raising questions
or concerns about the coroner’s process or they need information about options. It is also
the case that where Work Health and Safety Queensland (WHSQ) are investigating a fatality
an initial letter is sent to next of kin by the regulator. A whole of government guide A death
in the workplace – a guide for family and friends is also sent to the next of kin at this time.
This guide also refers to the coronial legal assistance service on page 16. A copy of the guide
is also on the website at this link: https://www.worksafe.qld.gov.au/injury-prevention-
safety/incidents-and-notifications/when-there-is-a-death-in-the-workplace. The Coronial
Assistance Legal Service is also referred to in the Office of Industrial Relations formal
correspondence with families and links are provided. This demonstrates an unevenness of
communication about the provision of legal support available to all families, with direct
communication dependent on the category of family or the type of reportable death. We are
also advised via private correspondence shared by the Office of the Public Advocate, that all
families under their ambit and where an inquest is occurring are referred to the Coronial Legal
Assistance Service.
This relationship between funding, communication of the service and its accessibility to all
families is currently unresolved. The replacement of the National Partnership of Legal
Assistance with the Coronial Assistance Legal Service Guidelines, and service provision
beyond the inquest has meant that Caxton and Townsville have had to both set parameters
to their service provision and/or turn families away. Townsville in particular have focused on
cases with a clear public interest including institutional and tourism settings as well as issues
related to rural and regional settings. It has also meant that Caxton and Townsville have
provided support over and above their funding agreements. Data provided by these
organisations includes taking on eight Aboriginal and Torres Strait islander families through
referrals from ATSILs, as well as 21 families identified as dealing with a mental illness or
disability and 12 culturally and linguistically diverse families.
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G. Method.
This evaluation is based on a four part method.
Parts 1 and 3: Interviews with 14 legal professionals and 10 families who have experienced a
coronial investigation and received support from the Coronial Legal Assistance Service.
For the legal professionals in Part 1 of the evaluation, selective sampling was utilised to
identify appropriate legal professionals to interview, and this was informed by conversations
with the two legal stakeholders being evaluated: Townsville Community Legal Centre and
Caxton Legal Centre. More specifically, Caxton and Townsville were asked to identify a range
of legal services and/or professionals who had some involvement with Coronial families in
either of the two community legal services during the trial period. As a consequence, 10
discrete professional roles were identified in two categories. “Coronial Engaged personnel”
include Coroners, In-house Counsel assisting, Coronial investigation officers, a member of the
Bar who has extensive coronial experience, and a member of the QPS Coronial Unit.
Questions for these engaged coronial personal included the following:
1. What has been your engagement with the coronial legal support service?
2. What value are these services adding to the experience of coronial families? Can you
give examples?
3. Are all families who need these legal support services having access? Can you give
examples?
4. Are there ways this service could be improved? Can you give examples?
5. Have you noticed a benefit to your own role from the provision of legal support from
community legal centres? Can you give examples?
“Referral organisations” included: ATSILS staff experienced in coronial investigations, and
representatives from the Public Advocates office, Community Legal Centres Queensland,
Industrial Relations Office, and Pro Bono Connect (previously QPILCH). Questions for referral
organisations included the following:
1. How did you hear about the legal services that have been introduced to assist families
in the coronial jurisdiction?
2. Do you understand the range of services that are provided by these legal services?
3. For what reasons have you referred families and what was the process?
4. What aspects of the service do you think are currently working well? How do you
know? Can you give specific examples?
5. Do you think there are ways to improve the services currently provided? If so, what
might they be?
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6. Have you received feedback from the families you have referred? What has been the
nature of this feedback?
The purpose of this first part of the project was to enable service providers to articulate the
ways in which they have engaged with the two community legal stakeholders under
evaluation, their observations of the value offered by these legal services, who has and should
have access, how the legal support offered could be improved, and whether they have
perceived a value to their own role or to the families supported during the trial period. We
received overwhelming support from these legal professionals and had a high rate of
acceptance of the interview request which was then conducted at a mutually convenient
time. Only two legal professionals who were identified could not take part due to conflicting
work schedules. Questions were sent prior to the interview and interviews were completed
face to face at either their own place of work or at an office at QUT or over phone or zoom
when the interviewee resided outside of Brisbane.
The third part of the evaluation was based on interviews with ten family members who have
had a loved one’s death investigated by the coronial system of Queensland and who have had
access to the Coronial Legal Assistance Service. The family’s self-selected into the process
after an email approach was sent by Coronial Legal Assistance Service staff to all families who
had accessed the Coronial Legal Assistance Service since May 2017 when the trial began.
Families approached the research team via email or phone and a mutually agreeable time for
the interview was organised between the family member and a team of two grief and trauma
psychologists. Interviews were structured and conducted face to face in offices at QUT or
over the phone.
• Families were asked six questions as follows:
• How did you hear about the services that have been introduced to assist families in
need with legal representation?
• Did you access any of the support services? If yes, what services did you access?
• How long did you access services for?
• Was that a sufficient period of time?
• What did you find most helpful about the services you used?
• Do you think there are ways to improve the services currently provided? If so, what
might they be?
Interviews normally took on average one hour to complete and were recorded and
transcribed and then sent back to each interviewee for approval. While the interviews with
the family members were structured to minimise any risks associated with recalling a
traumatic event in their lives, the interviews with the professionals were semi-structured.
This means that a set of questions were used as a guide, but new ideas were also discussed
as a result of what the interviewee might say. For the professionals the interviews were
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treated more as a social encounter while for the families, a more rigorous template of
questions and answers between the interviewer and the interviewee was followed. Our
previous experience has demonstrated to us that a semi-structured interview format works
best with high status individuals, allowing them to be involved in the meaning making of the
interview.
Parts 2 and 4: Survey of 26 legal and non-legal professionals and twenty families
For both surveys, the survey instrument for the wider community of professionals and
families was created once the interview data had been collected and analysed. This was to
enable the themes identified from the interviews to be further examined. For each
population, the survey consisted of demographic questions, questions which required a
definitive yes or no response, open ended questions which asked the respondents to offer
opinions or to clarify definitive responses, and evaluative questions which asked respondents
to rank the service on a scale of 1-10. An electronic survey was created and tested prior to it
being sent out to both groups. Professionals were identified by the Coroners Court of
Queensland and the two legal service providers, and all families received the email who had
utilised the Coronial Legal Service since its inception in 2017. The Survey instrument was
created using key survey and supported by QUT platform and server. The electronic survey
for the professionals can be accessed here: https://survey.qut.edu.au/f/193581/3efa/. The
electronic survey for the families can be accessed
here: https://survey.qut.edu.au/f/193908/2fc8/.
The survey of professionals was sent as a targeted email to all those who participated in the
interview, with instructions to forward the survey to others in a similar position. For example,
those coroners who were interviewed were sent the survey in an email with instructions to
send it to other coroners. The survey was also sent to organisations and personnel who had
not been targeted at the interview stage, including: Queensland Law Society policy team;
Director, Law Right; Project Director Secretariat, Coronial Services Governance Board; Family
Support Coordinator, Queensland Homicide Victims Support Group; Coronial Counsellors,
Forensic Services; Detective Inspector in charge, Coronial Support Unit; Principal Lawyer, Civil
Justice Services, Legal Aid Queensland; Director of Civil Law, ATSILS; Victim Support
Coordinator, Queensland Health Victim Support Service. The original email with the survey
attached was sent to identified above on 20 August, 2019. A follow up email with the survey
attached was sent on 23 September, 2019. The survey closed on 4 October, 2019.
The survey of families was sent via email by the two service providers to all families who had
accessed the Coronial Legal Assistance Scheme since its inception. Families completed the
survey by clicking on a link embedded in the email. The service providers do not know who
completed the survey and the research team did not directly contact any of the families. The
original email with the survey attached was sent to the legal service providers to be forwarded
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to families on 29th October 2019. Two further follow up emails with the survey attached were
sent to the service providers on 19th and 28th of November 2019, with a request that they be
forwarded onto the families. The survey closed on 6 December, 2019.
Low risk ethics approval was gained from QUT for the interviews and surveys of professionals.
(QUT Low Risk Ethics Approval no. 1900000101).
High risk ethics approval was gained from QUT for the interviews and survey of family
members (QUT Ethics Approval Number 1900000256).
Analysis
Thematic analysis was the key process utilised in this research and an inductive approach to
the data was favoured. Thematic analysis is one of the most widely used methodologies
within qualitative research (Boyatzis 1998). The main reason for this popularity is its
flexibility, in that it can be used across a range of conceptual and methodological
approaches. However, not only is it often regarded simply as an instrument that can be
successfully deployed within various different methodologies, it is also positioned by others
as a significant research method in its own right (Braun and Clarke 2006). At a practical level,
thematic analysis involves moving beyond a basic reporting of the research data, to making
an interpretation of the ideas, issues and activities existing within that data. This generally
requires an initial coding process, followed by the description and development of broader
themes consistent with that coding (Creswell 2014). Depending upon the epistemology of
the research, the themes can either emerge inductively from the data, or can be shaped
deductively by pre-existing research interests, which can, in turn, act to guide the coding
process; indeed, it is often the case that there is ongoing dialogue between the inductive and
deductive elements throughout a given thematic analysis. While thematic analysis is
employed in relation to a wide range of data and data-gathering techniques, arguably it is
most frequently employed in tandem with semi-structured interviews (Bradford and Cullen
2012).
As a method for identifying and analysing patterns within data, thematic analysis of the
interview transcripts and qualitative survey responses began with a process of schematic
coding, which required all responses to be read in their entirety. Using the interview and
survey questions as a guide, we identified key themes. Once key themes were identified,
dominant and emergent patterns were classified and then reviewed. Importantly, a key
theme does not necessarily depend on a ‘quantifiable measure’, but rather on whether it
captures something important in relation to the overall responses. The semi structured
interview format and open ended questions in the survey, enabled respondents to raise issues
of concern. In the interviews clarification on matters raised in previous interviews was sought
and the survey enabled the themes identified in the interviews to be clarified and explored.
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Profile of Family Members
All ten families interviewed have been involved in protracted coronial investigations. As a
consequence, they offer an insight into some of the more difficult and complex cases where
families have been particularly traumatised by the circumstances of the death and often, the
resulting investigation. In all cases one or both of the legal services under evaluation have
been involved in legally supporting these families. A general description of the ten families
and the death of their loved one are summarised here for reference to time frames and to
also identify the range of deaths, relationships and court proceedings that ensued. Unique
identifying information is deliberately excluded here and in the excerpts from the interviews.
The cases are as follows:
• Wife died in accident in 2017. Inquest in 2018. Findings handed down 2019
• Son died in workplace accident in 2016. No Inquest
• Husband died by suicide in 2016. No Inquest
• Wife died in hospital in 2017. No Inquest
• Son died in accident n.d. Inquest 2019. Still awaiting findings
• Husband died in hospital in 2017. No Inquest.
• Wife and son died in accident in 2011. Inquest and findings in 2015
• Daughter died in accident in 2015. Inquest in 2017. Findings handed down 2019
• Daughter died overseas in 2017. No Inquest
• Mother died in hospital in 2016. No Inquest
Limitations
All of the families who self selected to be interviewed for the evaluation had been engaged in
protracted coronial investigations of many years. For this reason, some of the findings from
these interviews may be dismissed as an exception to the general coronial population.
Similarly, the professionals identified by the Coronial Legal Assistance Service, may be
assumed to be biased in favour of the service. However, as noted above, the use of the survey
instrument was to explore and clarify the themes identified in the interviews. This report will
demonstrate that in both cases, the survey results confirmed the themes identified in the
interviews with both family members and professionals.
The survey results from both the professional group and the families are based on small
numbers of respondents and so cannot be considered statistically significant. However, given
that their purpose was predominantly to verify the findings from the interviews, and that in
each case the population surveyed was twice that of those interviewed, we consider our
recommendations to be based on valid insights into the operation of the Coronial Legal
Assistance Service.
15
As the survey was anonymous, it is not clear who of those interviewed also completed the
survey. However, given that the survey gained insights from twice the number of
interviewees, we do not consider that possibility to have biased the outcome. It should also
be recognised that our analysis is based on a qualitative thematic approach, rather than a
quantitative approach of statistical significance. We therefore do not consider that our
findings are skewed to a particular group of respondents.
H. Findings and Discussion: Part 1
Interviews with Legal Professionals
As a general rule we will offer indicative quotes from the legal professionals interviewed to
give a sense of the issues that have been raised, and that capture the central themes that
were identified in response to the interview questions.
Theme 1: Importance of legal service to support families
The first thing to note is that there was an overwhelming recognition that the provision of
legal support to families going through the coronial system is addressing a clear unmet need.
Issues raised to support this belief included:
• the emphasis on families in the Coroners Act (2003),
“Well the first thing is I think that it really emphasises that - as we know the Coroners Act 2003
was reformed to basically place a greater emphasis on families. All coroners, there's only seven
in this state including the state coroner, really try and prioritise the family. That's who at the
end of the day this is pretty much about ... I think a) a very clear message that families are
prioritised within the coronial system, b) that they [legal service providers] can match the
capacities of other legal representatives when they're trying to represent the interests of their
family member or their deceased family member” (Participant 12, engaged coronial personnel)
• the power imbalance that can occur during the inquest,
“I think there is just quite a power imbalance if you are going into a formal legal process and
you are not – you don’t have an understanding of how it operates and you don’t have someone
there who can frame questions and directly question the experts or the participants who in my
case, is the police officers or the corrective services officers who are involved in the matter”
(Participant 1, engaged coronial personnel).
• A family’s unfamiliarity with the coronial system and their lack of knowledge as to their
need for legal assistance.
I suspect it's a cohort that is less aware of their rights and responsibilities in this system,
because of the distressing nature and their vulnerability. It mightn't be seen as an area that
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they (a) do need to get legal assistance, so general members of the public are not very good
sometimes at identifying that they might need a legal service. So having a service at the door
of the Court or connected can be a way of even people realising that they might need to get
some legal assistance around the process, because it's not like a criminal process where they're
a defendant. … I can only guess that perhaps families are not going to prioritise paying for legal
advice in this area, because they may not even realise that they need legal advice in the first
place (Participant 14, referral organisation)
• the clear public interest matters that many inquests are engaged in examining
“In cases where someone has died, especially when they have died in the care of the state,
there is a public interest in the state – I mean the Police Commissioner and the Corrective
Services department, they are all represented and the hospitals and then the families are left
to their own devices which is not good” (Participant 4, engaged coronial personnel).
• technical expertise in an increasingly specialised area of law
“Yeah. I think it's a really valuable service providing the support and the specific expertise. It's
a really technical area of law. A lot of other Community Legal Centres don't have the technical
expertise to be able to give very much information or know very much about referrals or
services that are available so I think it's great to have that extra support in a specialised service.
I think it's really, yeah, really helpful” (Participant 11, referral organisation).
• Increasing access to justice for families
“So I think these services are great. They help people deal with death but they also serve that
larger public policy purpose of getting to the bottom of what happened. When people aren't
supported they can't participate in processes and so it actually isn't great for a system to have
people feeling as though it's not working for them. The justice system is meant to deliver for
the community, so I think the Caxton Coronial Service helps it to do that and it's a really positive
thing”. (Participant 7, referral organisation).
In contrast, there was also the clear recognition that not all families require or desire legal
support and that the system should be flexible enough to enable all families to work through
the system in their own way. This is supported by the Coroners Court Annual Report in so
far as many deaths are investigated “in chambers” and/or exit the system quickly. In 2017-
18, 5,812 deaths were reported to the Coroners Court of Queensland. Of these 1,850 were
found to be non-reportable and finalised relatively quickly. Only 52 inquests were held in
2017-2018 (Coroners Court of Queensland Annual Report 2017-2018). This tension between
legal support for all families as a matter of justice, and a concern that too much free legal
support will create a range of further problems, was a constant theme within the interviews
and will be explored in more detail throughout this discussion.
“I think some families; they are probably happy not to actively – some families choose not to
actively participate for different reasons or they are happy with – they are perhaps happy with
17
the way the investigation seems to be tracking along” (Participant 1, engaged coronial
personnel).
“Absolutely and some families don’t want to engage in the process and that’s fine. But those
families that are highly invested and highly emotive and it becomes obsessional for them, to
have someone to be able to be their advocate and to go through the process with them, is just
so incredibly beneficial, in my view” (Participant 4, engaged coronial personnel).
Theme 2: Positive Interactions with Service Providers: During the Inquest
There was strong positive support for the work being provided by Caxton and Townsville, both
during the inquest and outside of it. There was a clear recognition that both services have
provided immense value to the families they have supported, with a range of services
witnessed by, or fed back to legal professionals.
• Instructing solicitors and barristers appearing in the inquest
“I was extremely grateful that [legal provider] became involved. I think we directed him to
[legal provider] and said look we really think that you need some legal representation, you're
raising points that definitely require some attention. [Legal provider] took him on and the
advantage of [legal provider] taking him on in this case was that they also provided legal
representation on the ground in [region] through a local barrister and they had instructing
solicitors with that barrister …. I couldn't speak highly enough about [legal provider’s]
representation of [client] … I just can't imagine how that inquest would have run if [client] had
been representing [himself]” (Participant 12, engaged coronial personnel)
• Navigating the coronial process for families during the inquest
They have appeared in one … matter I had in [region] and they engaged counsel to act for the
family and I thought that was a very valuable process in that … there was some fairly complex
family dynamics. If the family had been unrepresented, it would have been a much more
difficult inquest to run, I think. I think [legal provider] helped the family understand what the
coronial process – what the limitations of it were, but also to focus in on the particular issues
about the way the police responded on that day (Participant 1, engaged coronial personnel).
• Appearing on behalf of families in the inquest
“I mean one of the staff said that families have said that they feel like they’re in a safe pair of
hands. I have been involved in inquests where [legal provider] have been representing families
and it’s good for – it’s a valuable resource for my staff to have an agency to whom they can
refer people and that you’ve got a degree of confidence that they will get a service, because
you can often – if you didn’t have this service you would be referring people to community legal
centres who might be able to provide them with some advice, or to a private solicitor that’s
going to cost them a lot of money” (Participant 5, Referral organisation).
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• Managing expectations of the family during and after the inquest
We very much appreciate that they [legal service providers] can support families to I guess
articulate why an inquest should be held or what other things the family might be asking a
coroner for. Just when families are coming with such emotion and unfamiliarity with the
jurisdiction, obviously having someone like [legal service provider] can help. But particularly
one that they [families] can receive for free and who has experience in the jurisdiction, then it’s
just so much better for the families and their experience of the system (Participant 3, engaged
legal personnel).
• Offering role clarity for counsel assisting
“Well I think there’s a – so there’s a benefit to the families, and then there’s a benefit to our
court in having families adequately represented. So that helps the judicial officer. It helps the
counsel assisting particularly and our admin staff, because once they’re represented [families]
we don’t need to become particularly involved. We [coronial court staff] shouldn’t become
involved, just like any legal situation, with the families. We don’t need to be – it’s a difficult
position” (Participant 2, engaged coronial personnel).
• Providing legal support for witnesses
“We have had three different occasions where we’ve approached [legal service provider] to ask
that they consider representing witnesses at an inquest. They have agreed and have appeared
for witnesses … Obviously with our deaths people involved in deaths reported to coroners who
come and give evidence can sometimes be persons who might be criticized in relation to their
involvement in that death. Sometimes in very direct ways … where we’ve contacted [legal
service provider] and said, hey, we’re really concerned about this [the witness]. We understand
they don’t have representation, are you willing to [represent the witness] if I put you in touch,
to have a conversation with them to see whether you can assist? Each time they did as well.
So again another really valuable resource” (Participant 3, engaged coronial personnel).
Theme 2: Positive Interactions with Service Providers – outside the Inquest
Generally speaking, the legal professionals were supportive of the way in which the provision
of legal services by Caxton and Townsville enabled families to participate in the process. It
was agreed that both service providers offered empathy as well as a strong understanding of,
and expertise in, the coronial system. They were also able to clearly identify a range of tasks
that had been performed by the Coronial Assistance Legal Services during the time period.
• Legally representing the family to access materials and reports
“The [legal service provider] were involved with the family for the deceased in terms of
advocating for matters that the deceased family considered relevant during the inquest. So
providing that level of advocacy, but also coordinating with us in terms of the release of certain
material that the families might have wanted. That can be anything from autopsy reports or
19
we might be getting reports in from other stakeholders who, in terms of let's say workplace
health and safety - and the family might want to obtain a copy of that. So [the legal service
provider] can act as that legal representation for the family to get that material, but
additionally from our perspective they also provide that extra really invaluable level of service
in terms of not just handing the material over, but also being able to talk a next-of-kin through
the material. What it means; what the implications are for the circumstances surrounding the
death of their family member” (Participant 12, engaged coronial personnel).
• Making applications for inquests and other submissions to coroners
“As to we get to the investigation, they [legal service provider] quite often make applications
for an inquest to be held … they [legal service provider] now have some considerable experience
in the coronial field so they know the limitations and they know how we operate and they’re
able to really proceed along on that basis” (Participant 2, engaged coronial personnel).
• Offering family liaison and support
“I think just again that constant liaison with the family, explaining to them why [the coroner’s]
made a decision or why the matter adjourns. Something that we don’t generally have capacity
to do or are able to do particularly with some families if they’re represented as well by private
[solicitors]. I think there’s just this level of support [provided by legal service provider] that even
private barristers and instructors probably don’t give. They have that empathy in there, the
understanding of the jurisdiction. I don’t think – they do a fantastic job and I don’t know what
more they can provide because they are doing such a really good job with the families”
(Participant 10, engaged coronial personnel)
• Mediating in body disputes
“Yeah and I think we've had a couple of matters where someone's gone to [legal service
provider] and we've represented the other - I think the case [name redacted] did went to
Supreme Court over a body dispute and I think we had that other one where we - it was
mediated so they didn't have to go to court. So we've had some contact and I know [name
redacted] said that the staff at [legal service provider] were wonderful to work with … we were
sort of working together to try and get the best result for the families” (Participant 8, referral
organisation).
• Explanation of the process
“I think it's really where there's a lot more - where families feel a lot more - when they need
more information about what's the coronial process. For instance, why are we getting the
toxicology report or why are we getting these reports; being able to explain those processes.
That's when those services can really come in and be useful” (Participant 13, engaged coronial
personnel).
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Theme 3: Lack of Uniformity in the Referral Process
The theme of communication was central to the interviewees and appropriate
communication with families was one of the key issues identified in the interviews and
brought to light a range of competing concerns over the purpose of the coronial legal
assistance service, and how best to appraise families of its availability. As the following
discussion demonstrates, legal professionals interviewed do not agree on this point. In
particular, there is debate about how families should be notified and which families should
be notified. A number of legal professionals expressed some concern as to the impact of a
generic notification on Caxton and Townsville as well as on the jurisdiction as a whole.
Those who advocated for a case dependent approach favoured familial need and case by
case discretion to refer to Caxton or Townsville.
• Concern over workload implications
“I don’t think that every single family needs that [legal support offered by the services] and
because there are so many different types of death that we can investigate, some may not be
necessary to refer that [to the legal services]. There’s other avenues, there’s other investigative
bodies that can assist families in their concerns for conduct issues and that sort of thing,
something that is not within our scope … I think it’ll increase the workload a lot [referring all
families] but I don’t know if that’s a consideration. It’s hard to assess” (Participant 10, engaged
coronial personnel).
• Referral based on perceived emotional need
“We try and identify early on those families who do have a real vested emotional interest in
the process and are obviously going to be deeply engaged in it. But have particular views that
we’re worried we’re not going to be able to fulfil what they need in terms of having an advocate
for them. They’re [families not supported by legal services] going to walk away from the
process feeling really disappointed to say the least, frustrated, angry because there hasn’t been
anyone who has been a voice for them in the [coronial] process” (Participant 3, engaged
coronial personnel)
• Recognition that families can be strong advocates for themselves
I wouldn't say that there should be a - everyone gets a support service package. It just depends
on what they need - what they feel they need and trying to meet that as best as possible …
some of the families that I've met are actually very good advocates in their own right in terms
of being able to advocate for their next-of-kin deceased. So I would say as a rule I don't think
every family, even in complex matters, necessarily would need to have that support. I think it
just depends on their own level of understanding of the material and their ability to engage,
but as I say, some families feel very competent to be able to interact on their own (Participant
13, engaged coronial personnel)
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• A concern over timing and overburdening the sector
“Look, we’ve had this discussion about the timing of when we should inform families that there
is this resource. I’ve been reluctant to bring that on too early. I think it was a question – it was
a discussion we had only just a little while ago. I said, look, we really do need to talk to [legal
service provider] about what their capacity is to have this letter being sent out early in the
piece. We haven’t had the discussion with them … So I was reluctant to have a standard letter
sent out saying, you can contact [legal service provider] at the very beginning, because I think
people might, and I think they become overburdened in my view” (Participant 2, engaged
coronial personnel)
In contrast a number of legal professionals see value in all families being notified from the
beginning of a coronial investigation, to ensure that free legal support is available to help
them navigate the system in its entirety.
• Notifying all families as standard process
So we’ve built it into our processes and procedures. We’ve got the – so the staff are on the
phone to the families so they know that if they’re raising issues around they want an inquest
or they don’t want an inquest, or they don’t know what’s going on in the court, the staff know
that they can just tell the person about the [legal] service. We’ve also got the brochure that
we can email them (Participant 6, referral organisation)
• Legal support as an important safety net
“Exactly. They would slip through the system. These people were educated, understand how
to use and work systems. For those who aren't and who have other difficult and distracting
things in their lives, they're going to give up and it's really - and often it's the disadvantaged
who are the ones who are at greatest risk of that, for things to be going wrong in their lives
and to end up in these systems anyway. So, it's really problematic. We need to have some
better safety nets for them” (Participant 7, referral organisation)
Theme 4: Poor Communication between legal organisations
Continuing on with the theme of communication, some legal professionals interviewed also
raised concerns about the communication between legal, government and non-government
organisations, and how they might best support families and offer streamlined services.
These interviews did demonstrate that there was poor communication between
organisations when the coronial assistance legal service was piloted in 2017.
• Indirect notification of the legal service
“I think really through Townsville. I think that was probably how we knew about it. We receive
applications from everyone in Queensland, like people all around Queensland, so we I guess in
some ways try to be a little bit aware of what's going on in other CLCs so that we can refer
22
matters that we can't assist with quite efficiently. We do try and give people directed referrals,
so you should try this particular CLC or this one that specialises in this. We do try and keep on
top of it when we can but I think we were made aware by Townsville approaching us about a
particular matter. That's when we worked out that Caxton were doing it as well … Because I
don't think all this information is passed on very well across industry wide. I think that that's a
bit of a problem. I think that we all could improve that industry wide” (Participant 11, referral
organisation).
• Lack of knowledge of the legal service
“I: what’s your engagement with the coronial legal support service? So there’s one in [region]
S: There’s one in [region]? I wasn’t aware of that.
I: So you didn’t know it was there?
S: No, and I’ve never been contacted by them.
I: And you’ve never referred any families to them?
S: No. Well there was no sale of the product, no visibility” (Participant 5, engaged coronial
personnel)
• Lack of referral by Coroners
“I don’t think there’s been the uptake by some of the coroners necessarily of referral to [legal
service provider]. And they’re aware, they’ve been part of the process … it does depend on the
case and the coroner. As I understand and I haven’t seen their [coroners court] preliminary
letters, but the idea was that their preliminary letter to families was going to have a link and a
description of the service. But I don’t know if that’s happened” (Participant 4, engaged coronial
personnel)
• Need for a streamlined approach
“The only thing I could think of was whether there is some need, and I don’t know whether
there is, for having a more simplified or a streamlined or a process for referring families to the
[legal] service” (Participant 3, engaged coronial personnel).
Theme 5: Who should have access to free legal support
Underlying the debate about how best to communicate to families, and who should be
referred to the system, and how this should occur, are the key (competing) themes of
resourcing and vulnerability in the coronial jurisdiction. On the one hand, public funding for
legal support is low across the sector, and many alternative sources have a means test or
public interest test that is onerous to fulfil. Moreover, there is some concern that freely
available legal support may unnecessarily increase demand for a service. On the other, the
public interest element of the jurisdiction, the small numbers of families and the trauma and
grief should mean that legal support should be available.
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• Concern about an artificially inflated demand
“There would be some in government who would think, well, when you fund a service like that,
it drives demand for the coronial service and of course, they already can't keep up with the
demand that they've got. That's the hard stuff” (Participant 7, referral organisation).
• Concern over competing claims for support
“It is a difficult thing to say to a family yeah you can be represented and you’re going to have
to pay for it in circumstances like this where they have suffered a tremendous loss. On the
other hand, providing these services to people that might otherwise be able to afford them
must – well potentially means that other people who can’t afford them, either this service or
another legal service, aren’t getting it. So that’s all I can say…..look people who could afford it
might well choose to be represented by their own lawyers who they’re going to pay. That might
be a decision that people make. I’m not – I’d be speculating as to whether anyone we’ve
referred to the service might otherwise have had the means to pay for it” (Participant 6, referral
organisation).
• The relationship between capacity and desire to support families
“So we don't get any additional funding to brief barristers. So it makes it pretty hard to - like
our information fact sheet basically says we can assist families, but we don't actually have a
lot of funding for it” (Participant 9, referral organisation).
• Competing thresholds of eligibility in the sector causing concern
“Then I guess for us it's about considering that eligibility as well. If it is that these matters are,
you know, means are not to be considered in these particular matters and we're supposed to
focus on other things, we're happy to take the view of the other CLCs and which we did with
this particular one. But that's a bit of a - just a bit of a sticking point for us that we need to
think about that and what our members are expecting for us to do and what the public interest
element of the matter is. I think the hardest thing is for us and it sounds quite harsh when you
put it so bluntly, but unfortunately the resources make a big decision, like make a big, well,
have a huge impact on which matters we can and can't take on. That's where that eligibility
and having differences in eligibility criteria between these two services is a little bit of a
challenge for all involved. Because for us ultimately the one thing that I want to look at when
I decide whether to take one matter over another, when we can only take on a certain amount,
we've only got the resources to do so many, is can that person get help anywhere else?”
(Participant 11, referral organisation).
• A recognition of vulnerability appropriate to the jurisdiction
“Yeah, look, I think the discussion in the sector is that vulnerable and disadvantage is a moving
concept and it's a moment in time in people's life. You can not be in that category one day and
then experience something in your life that changes things and but for the grace of God many
of us are not in those circumstances. So I think [pauses] - look, I'm not entirely sure about how
24
the discussion went around disadvantage. But I suspect because it is such a small cohort of
potential clients you don't have to narrow the funnels too much, so you can just accept
vulnerability as a criteria. Whereas I think in other services, say in family law services where
there is a much greater cohort of people looking for those services, you need to narrow the
funnel a bit. So having the two linked can focus on priority clients” (Participant 14, referral
organisation).
• The importance of public interest to the jurisdiction
“Yeah, I think so. I mean I think there are public interest issues that can come up no matter
what the scenario is. Most people who end up engaged in the coronial system aren’t
necessarily particularly wealthy anyway, particularly in my types of matters where they’re
prisoners or people that are interacting with police” (Participant 1, engaged coronial
personnel).
Theme 6: Unmet needs within the provision of legal support
a) Disbursements
Aside from discussing the ways in which Caxton and Townsville had fulfilled their brief, legal
professionals were asked about areas of unmet need. One area of unmet need that sits within
the scope of this evaluation concerns the capacity for Caxton and Townsville to cover the
costs of travel for probono barristers and solicitors appearing on behalf of families during an
inquest. This was considered to be a disincentive, especially outside the south east.
“For the one that we didn't have picked up that I was mentioning before, that was in [region]
and we couldn't find - they needed somebody to attend in [region]and we couldn't find
somebody to attend in [region]. Our list of barristers in [region] is very small compared to our
list in South East Queensland so that's a big part of it as well. We may have been able to find
a barrister in Brisbane who could do it if we had been able to pay the costs to travel”
(Participant 4, engaged coronial personnel).
“Sometimes, yeah, if their costs are paid, but it also depends on - sometimes it's something as
simple as scheduling or how long something is going to be or all those sorts of things as well.
It's much easier for us to get matters picked up for something if it's going to take a day than
something that's going to take a week, for example. As I'm sure you can appreciate that's a
bit investing of time to have somebody block out a whole week for pro bono work” (Participant
11, referral organisation).
a) Transcripts
The difficulty and cost of accessing transcripts in the coronial jurisdiction was noted by a
number of interviewees as an issue worth feeding back. It was considered to be a further way
in which these families were lacking legal support.
25
• Costs
“We have had some feedback [from families] around the cost of transcripts of inquests and I
don’t know if that’s an impact upon the legal service. I don’t know of they’ve got some
arrangement around access to the transcripts……and everybody who wants a transcript
basically unless you apply for a fee-waiver through JAG you’re paying for a transcript. The cost
is probably outside the reach of a lot of people” (Participant 6, referral organisation).
• Lack of access
“I have to say I'm not quite understanding what the impediment is and the cost and that does
need really to be looked at … I don't know what the issue is within our own court system. It
seems absolutely ridiculous to me. I've said to the state coroner I consider a transcript a tool
of trade. If I want to go back and cross-reference something, a note that I made against
something that I thought was said that's going to inform a finding, I should have access to that
transcript. That shouldn't even be questioned” (Participant 12, engaged coronial personnel).
• Barriers to legal process
“That's an issue across the Court system in transcripts, accessing transcripts. So in other
jurisdictions that's the same, so I think that's a systems issue. It's an access to justice issue for
people, particularly who are representing themselves, to have those, the resources. I absolutely
know that that is an issue and I guess we would be interested in is that a barrier to being able
to access process, which in other jurisdictions it can be” (Participant 14, referral organisation).
Theme 7: unmet needs beyond the provision of legal support
Emotional support and counselling was most often discussed in the interviews in response to
the question of unmet need and was partly in recognition of the decreased service offered to
families through the coronial counselling unit, as well as an understanding that the coronial
system can be a very emotional and traumatic jurisdiction for families. For the evaluation, it
was also due to the recognition that the service providers under evaluation, specifically
Caxton, have at times provided their social worker to support coronial clients.
b) Emotional support and counselling
• Current counselling services overwhelmed
“Yeah, I mean I think that would be helpful because the Forensic Scientific Services only offer
the counselling support while the bodies are going through the post-mortem phase. So once
the bodies are released, they tend not to have much to do with families as the system carries
on and that was one of the themes that the QAO had that basically once people get that initial
support, they are pretty much left unsupported” (Participant 1, engaged coronial personnel)
26
• Support for an embedded court counselling service
“I think it is a good idea.- [legal service provider] could provide the service but it seems to me
that it is a service that should support the court process. So, in my view, it should be something
that is funded out of the coroner's office. I think the coroner would really like to have family
liaison officers because I'm sure that they, both [name redacted] and [name redacted], really -
they're very caring people and you wouldn't do this job if you didn't care about it. You would
carry a lot of it with you as well” (Participant 7, referral organisation)
• Recognition of a traumatic jurisdiction
“The bigger picture is this is a really traumatizing process and we can’t always predict what is
going to cause a family trauma as well and what support they need. So if there is someone
who has that particular focus [counselling] as their role, rather than counsel assisting and the
investigating officer … I mean we do our best but it’s not our focus……there’s not much time
we can dedicate to that” (Participant 3, engaged coronial personnel).
• Trauma exacerbated by delays
“Because I think one of the things that we're certainly seeing is - because some of the delays
that can be experienced during the coronial investigation certainly for some family members
that really also prolongs the grief process for them once the person has died. So even though
a person might have died 12 months down the track there's still investigation going”
(Participant 13, engaged coronial personnel).
• Lack of embedded support services for families
“It's traumatising to relive all of that so we had a local counselling service but all of this once
again is only really the initiative of any particular client. They're not formalised entrenched
embedded processes” (Participant 12, engaged coronial personnel).
c) Witnesses
In a similar fashion, the support of witnesses was raised by a number of legal professionals.
It was also disclosed by interviewees that Caxton and Townsville are providing legal support
for witnesses as part of their current legal work with the coronial system. The evaluation
team were also able to witness this issue first hand when observing an inquest where Caxton
were representing the family. In this inquest a witness required considerable emotional
support during their testimony and this was compounded by the fact that they were offering
testimony via an audio link. The witness became so distraught that the proceeding was halted
and the presiding coroner sent police to the premises of the witness to check that they did
not need assistance. It was also discussed during interviews that in lieu of other support being
provided, that coroners and other court personnel have set up their own practices to support
witnesses appearing in court.
27
• Delays exacerbating trauma for witnesses
“it’s going to court in any jurisdiction is scary but reliving a very traumatic offence is very
compounding….that witness’s reaction….we’re not aware of what’s going through their mind.
We don’t know if they have received any support at all since the death. Then two year down
the track we send a summons and say you need to come to court. It’s scary because you just
don’t know how people are going to react. I think that was a prime example of the need for
having extra support for witnesses because there really is none” (Participant 10, engaged
coronial personnel)
• Vulnerability of Civilian witnesses
“I guess it depends because you'll have some - a lot of institutional witnesses so we might be
calling people from Queensland Ambulance Service, Queensland Police, Foreign Emergency
and the hospitals. So they're all going to have within their own institutions their own support
networks so we tend not to focus too much on those witnesses. But then it's really the civilian
witnesses that are not coming in from any sort of institutional framework to give evidence. The
example might be we've got an inquest coming up in relation to the {specific case] where we're
asking people who were there on the day, just residents of [region] or the surrounding areas to
come in and give evidence about what was a traumatic incident” (Participant 13, engaged
coronial personnel).
• Implications of witnesses appearing in the coronial jurisdiction
“All I've done in relation to witness support because there isn't any, is that there's a huge
burden basically on counsel assisting who the last thing they need going into a five or six day
inquest is having to triage witnesses and also be that person. What I do is I normally call on -
until recently I called on the court chaplain. I introduced him to everyone at the beginning of
the inquest. All of this is at my own initiative about how do we look after the people who might
be unravelling behind the scene. He came to debrief me without giving me any names, about
three weeks later and he said I'm not sure if you're aware but he said almost every one of the
[professional staff] that were called in the inquest actually followed up with me. They were
really quite traumatised and distressed that their whole professional reputation's on the line
potentially, with all that's been reported in [media] that their names are now completely
forever cached in Google searches.” (Participant 12, engaged coronial personnel).
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Conclusions to Part 1
Based on the questions and the analysis, we identified seven themes that were used to inform
part 2 of the method: the survey of legal and non-legal professionals. The seven themes are
as follows:
1. The importance of the Coronial Legal Assistance Service to support families in the
coronial jurisdiction based on a clear unmet need
2. The value added by the legal service providers to families and to coronial personnel
within and beyond the inquest
3. A conflict over how and when to best communicate the availability of coronial legal
assistance service to families
4. The poor communication between legal, government and non-government
organisations about the coronial legal assistance service, and how this impacts on
a supportive and streamlined service.
5. How the limited resources attached the Coronial Legal Service should best be utilised,
in the context of the increasing legal complexity and specialisation required of legal
support in the coronial jurisdiction
6. The difficulties attached to offering probono legal support in the coronial jurisdiction,
especially outside the south east.
7. the vulnerability of the families and the traumatic nature of the jurisdiction and the
subsequent need for counselling/emotional support to families and witnesses
Some of these speak directly to the issues canvassed in the questions, while others arose in
the context of the conversations in the interviews. These themes were explored in more
detail in the survey of legal and non-legal professionals in the sector.
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I. Findings and Discussion Part 2 Survey of legal and non-legal professionals
The purpose of this second stage of data gathering and analysis was to extend the preliminary
findings from the interviews conducted with key legal stakeholders about the Coronial Legal
Assistance Service.
Quantitative Results This first section describes the quantitative results gleaned from the survey, including
respondent’s demographic information, their ranking of the value and satisfaction with the
service and any questions that required a definitive yes or no answer.
a) Demographics (Q1, Q2, Q3, Q4)
Age and Gender - 16 women and 10 men responded with ages ranging from 24-67 with the
majority over 40. More specifically, 20-29 = 1; 30-39 = 6; 40-49 = 6; 50-59 = 9; 60-69 = 3
Qualifications - Qualifications ranged from Certificates to Masters degrees, with the majority
holding a Bachelors qualification.
Of those who responded, the majority had legal backgrounds. More specifically, Certificate =
1; Diploma/advanced diploma = 3; Bachelors = 25 (some had double degrees); LLB = 15;
Bachelor of Nursing (1) /counselling (1) /commerce (1)/arts (6)/social work (1); Graduate
certificate = 2; Graduate diploma = 2; Masters = 5 (LLM – 3; social work – 1; science – 1)
Roles - Fifteen of those who responded had a role within the coroners court, including
coroners and other legal roles as well as administrative and professional support, and policing
roles.
Eleven of those who responded had roles outside the coroners court, including staff attached
to referral organisations like OIR, ATSILS, and Public Advocate as well as social workers,
lawyers and barristers and coronial counsellors.
b) Awareness of and Access to the Service (Q5, Q6, Q8, Q10, Q11, Q13, Q16)
Awareness - The vast majority of respondents (24 of 26) were aware of the Coronial
Assistance Legal Service offered by Caxton and Townsville. How they became aware of the
service varied. Ten were made aware through their place of employment, though only three
noted that this was a systematic process. Four found out through their professional networks
and six were informed by either of the two contracted legal providers (Caxton or Townsville).
One found out by being involved in this research project.
30
Referral process - The majority (22 of 26) of respondents maintained that their organisation
did have a referral process in place. However, when they were asked to describe the process,
a lack of clarity was evident in the responses.
Number of families referred - The majority of respondents had referred very few families to
the service. Six had referred between 1-2 families, four had referred 3-4 families and three
had referred 5-10 families. Two had referred between 10-15, while one respondent
suggested they had referred up to 30, and one around 20.
Range of legal services required - When respondents were asked to identify the range of legal
support these families required from a pre-existing list, the majority of the respondents
identified the inquest (13), request for inquest (13), or review of decision by coroner (9) as
the central reasons why families would have been referred.
Contested burials (6) or request for documents or information (6) were also identified as key
areas for which families required legal support.
Explanation of burial process (3) or burial assistance (1) were less likely reasons for families
to be referred. Other matters such as advice on property, legal and family matters (1), or
advice about medical negligence/dependency claims (1) were also rare.
Access - When respondents were asked if all families that need these services are having
access to them, the majority replied in the negative – No = 14; Yes = 7.
c) Evaluation of the Service (Q14, Q17, Q18, Q19)
Feedback - A number of respondents reported having no feedback from families they have
referred (5), but the majority of the feedback received (10) either directly or anecdotally was
overwhelmingly positive about Caxton and Townsville. Only one respondent identified
negative feedback from a client.
Usefulness of the Service - Respondents were asked to rate the usefulness of the service. The
majority rated the service very highly:
10/10 (12); 9/10 (2); 8/10 = 4; 7/10 = 1; 6/10 = 1 and 4/10 = 1.
Satisfaction with the Service - Respondents were asked to comment on their satisfaction with
the support the family received. Again the majority rated the service very highly:
10/10 (12); 9/10 (3); 8/10 (3); 7/10 (1); 6/10 (1) and 4/10 (1).
Value to their own Role - When respondents were asked to reflect on whether the provision
of these legal services added benefit to their own role, the majority of respondents (14) had
noticed a benefit while seven had not.
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d) Preliminary conclusions
Demographics: Despite the small number of respondents, there was a representative spread
across age and gender. Roles were also well spread between those placed in the Coroners
Court and those working in organisations which support or interact with families negotiating
the coronial process. The dominance of the legal profession was evident in the qualifications.
Value: The Coronial Legal Assistance Service was rated highly by respondents, indicating the
usefulness of, and satisfaction with the Service for families. It was also clear that a majority
of respondents considered the support of families through this Service was adding value to
their own role.
Awareness and Access: The respondents were most critical of the way in which the Service
has been communicated to both themselves and to the families. There was a lack of clarity
evident in the referral process, and the majority of respondents had referred few families
since the Service trial commenced. Despite this low referral rate, the majority were of the
opinion that not all families needing support are gaining access to the Service.
These preliminary conclusions were explored in detail through the exploratory questions
within the survey which sought more information from respondents about these issues.
Qualitative results
The discussion here will explore the survey results in more detail, reflecting on the issues
raised in the quantitative results noted above as well as with the interviews that preceded
the survey, comparing and contrasting where appropriate. This analysis is thematic rather
than descriptive, and so questions have been conflated to identify the key issues raised across
questions. The conflated analysis is indicated through the identification of the relevant
questions informing the theme.
Access to the Coronial Legal Assistance Service (Q7, Q9, Q12)
The interviews revealed a lack of clarity about how families should be notified and which
families should be notified. This lack of clarity was also evident in the survey in two key areas:
when respondents were asked to describe the range of services that the Coronial Legal
Assistance Services offered, and when they discussed the referral process in their
organisation.
a) Understanding of the range of legal services offered.
The majority (16) of respondents in the survey understood the services to be available to
support families broadly at all stages of a coronial investigation.
32
The services are available to support families at any stage in the coronial investigation
process, from beginning to end, with or without inquest or when seeking a review of
coronial decisions and including applications for reopening inquest and representation
at inquest.
Legal advice re: all coronial processes, represent family at pre-inquest conference and
inquests where relevant. Statewide service, phone and face to face appointments
My understanding is that the support includes initial advice about the coronial process
up to preparation for and representation in an inquest.
Five respondents thought that support was more targeted and for complex investigations or
for support at inquest.
Limited support subject to funding community legal services for legal advice and in some
cases representation at inquest.
My understanding is that legal support can be provided to persons involved in a coronial
investigation process if it meets casework guidelines.
Three respondents were not sure of what was offered though this did not stop them from
referring families
No idea. Just refer families to them when families ask for assistance. I do not know the
level of funding/resources available. I generally refer any families who would be unable
to afford private representation (which is almost families).
These qualitative survey results indicate that a systematic approach to informing staff of the
parameters of the Service, both within and outside the Coroners Court of Queensland, is
lacking, and that as a consequence, respondents have relied on informal networks or the
service providers themselves to be made aware of the existence of the Service, and its
mandate. This continues the concerns raised in the interviews, which demonstrated a lack of
clear communication between organisations about the Coronial Legal Assistance Service
when it was piloted in 2017.
b) Referral Process
As noted in the interviews with key legal stakeholders, how families were given information
about the legal assistance service, and which families were notified, was identified as a key
issue requiring clarification. This was also evident in the survey results. While the majority
confirmed the existence of a referral process in their organisation, their descriptions of the
process lacked any information about when a referral might occur, or which families might
be given the information. This was evident in sixteen of the responses.
Refer via email or via telephone or formal letter
Usually a warm referral through a phone call, then follow up documentation as required.
33
Advise persons in writing and over the phone
At an appropriate stage family is advised of the service
Advised by IIT (inquest and investigation officer) or CA (counsel assisting) re: availability
and put in touch
In contrast, six respondents did identify a clearer process, suggesting that families are only
referred once a legal issue has arisen, or if a family are seeking legal advice.
Case by case basis. I will refer any person I have contact with who has questions about
legal aspects of investigation process.
If I am involved in an inquest and consider it would assist the process I will refer the
family to the service
Staff identify individual families as potentially needing independent legal advice in
relation to coronial investigation.
One respondent noted that all families going to inquest in her office are referred to
Caxton/Townsville while another respondent identified no formal process within the CCQ.
It is clear from the survey and the interviews that there is no formal process in CCQ for
referring families. Without a clear referral process, families are apprised of the service in a
discretionary manner, with staff reacting to problems as they arise or if they come to their
attention (and who must also have knowledge of the Service and its mandate to enable a
referral). It is also the case that some referral organisations, as noted in the survey responses
and in the interviews, refer all families once an inquest has been organised.
c) Reasons for Referring Families
The survey sought some clarity over the referral process, by asking respondents to describe
why they might have referred a family to the Coronial Legal Assistance Service. The majority
indicated that they referred families for generic legal support who either asked for help (3),
demonstrated a need for legal support (3) or who it was determined would benefit from legal
support (3).
They have sought legal assistance or would benefit from it.
Nature of family’s interaction with coronial process/registry indicates need for them to
be informed by independent legal advice
I felt they were struggling with the process and needed additional support than what I
as Counsel assisting could provide
I referred the family to the service because I thought it would be an appropriate service
to provide advice and support the family through the coronial process
34
Some respondents referred families for help with specific legal issues such as complex legal
questions (5) and/or the scheduling of an inquest (4). Irrespective of why families were
referred, all respondents demonstrated a preference for a discretionary approach to the
referral process.
Legal advice about impact of engaging in open disclosure process when NOK is still
providing info about concerns for Coroners consideration.
So that families and witnesses can be legally represented at an inquest (particularly
where the family has a strong view about the circumstances of the death of their loved
one or where the witness may be subject of adverse comment by a coroner or may need
to claim privilege against self- incrimination when giving evidence at the inquest).
The survey has demonstrated a confusing array of responses to questions about the range of
services provided by the Coronial Legal Assistance Service, and the reasons why staff might
refer families. Respondents appear divided on whether the purpose of the Coronial Legal
Assistance Service is to provide legal support for families in a generic sense and at all stages
of the investigation, or if they are to solve only the complex legal problems of those families
who are struggling/emotional/stressed by the process and/or need representation at Inquest.
It is also the case that despite referring few families themselves, the majority consider that
not all families are gaining the support they need. It could be surmised that staff are acting
as gate-keepers to the Service, referring only those families who demonstrate the greatest
need. This was also evident in the interviews, where concerns over the capacity of the
Services and over-legalising the sector, were cited as reasons for a discretionary approach.
Value added by the service (Q15, Q20, Q21)
Three questions in the survey asked respondents to identify the value added by the service,
either to the families or to their own roles as well as to reflect on what was working well in
the provision of the Coronial Legal Assistance Service. These questions did raise similar
themes about the value added to families and the value added to the respondents roles. For
these reasons they have been dealt with thematically.
a) Value added to the experiences of families
There is overwhelming support from the respondents for the provision of a Coronial Legal
Assistance Service, with the majority (21) agreeing that the Service provides families with
legal support and assistance that is otherwise unavailable in the sector, helping them navigate
a complex jurisdiction when they are stressed and traumatised, and offering them a voice
during the process. Four respondents noted the value offered by the Service to the coronial
process, to their own role or to referral organisations.
Information and understanding of the process (9)
Better understanding of coronial processes and overall improved access to information
35
Independent advice and assistance to understand the coronial process and its limitations
This is a very valuable service and provides assistance that it would otherwise be difficult
for families to receive
Help navigating the coronial system at a time of stress and trauma (6)
I think it is great as it assists into an area where people are in a bad spot and need as
much help as possible. Takes some pressure off the families in progressing their rights
and access to information
There is improved support for bereaved families through the coronial process. The
process can be explained in simple terms by the legal staff. Families have the capacity
to have their concerns addressed in the process.
The service makes it easier for grieving families to navigate and understand a complex
coronial process in a time when they are experiencing a great deal of stress and pain
Advocacy and a voice for families in the process (6)
I am of the firm belief that this is a very valuable service. This is particularly when costs
are not recoverable in the jurisdiction. To engage their own legal representation is often
prohibitive. To have their own representation ensures that they feel truly a part of the
process and can ventilate their concerns to seek the answers that may be stopping them
from moving forward.
From my observations, the family is receiving assistance that is helping them to
meaningfully engage with the coronial process and raise issues of concern to them about
the treatment of their family member in the days prior to his death. They are more
empowered and more able to participate in the process in a way that allows them to
undertake one last act of advocacy on behalf of their family member.
Allow them to be heard and have someone advocating on their behalf and have the
separation from Counsel assisting who may not be able to seek/ask the questions the
family require.
There is clear support for the independent advice and advocacy offered to families by the
Coronial Legal Assistance Service.
b) Value provided to the professional’s role
Following on from the perceived value offered by the Service to families, respondents were
also asked to specifically reflect on the value offered to their own role. The majority perceived
a value, often mirroring the value identified for families - enabling coronial processes to run
smoothly and providing independent advice and advocacy. However, there was also a value
identified by non-legal professionals outside the coronial system that had not previously been
noted.
36
Adding value and support outside our skill set (4)
In the fact that they are getting information from a lawyer, and goes into areas we are
not involved in, as generally our procedural involvement with the family is more or less
completed.
The lawyer assisting the family is assisting me in my role by providing me with
information about processes and giving me updates in a timely manner. This enables
me to more effectively support the family both emotionally and practically.
Communication is excellent and this decreases the risks of secondary systems trauma.
They can provide advice on legal matters that are not within the scope of the coronial
jurisdiction
Aiding coronial staff (2) and picking up the shortfall from other agencies (1)
I believe they add value as [referral organisation] receives very limited funding for
coronial matters, and disputes over the release of bodies occurs quite frequently.
If these services were better known it would reduce contact by NOK to me seeking
answers to legal matters
Court processes run more smoothly (11)
When a family who is highly emotional and or angry, the whole process of an inquest
runs so much more smoothly when they have their own legal representation.
To assist with coronial inquest matters we would have had to refer applicants to member
firms or barristers for even general advice. The service can now assist with such advice
without the need for referral to a private lawyer.
When parties are represented it assists in respect to alleviating pressure on legal counsel
as persons are better informed. They have an alternate source for information and
support
Independent advocacy and advice (12)
A coroner is always assisted by families receiving independent legal advice and
representation – as is the counsel assisting the inquest who is then not required to do all
the heavy lifting/and occasionally in conflict with family interests.
Independent advice and assistance to understand the coronial process and its
limitations. Improved advocacy and communication of family’s concerns/issues for
coroner to consider. Improved participation by families in Inquest process. Also reduced
administrative burden for registry staff in dealing with family contact.
37
The satisfaction families get out of being represented at inquests is invaluable and the
assistance with contested burials and workplace death investigations assists in bringing
them closure of the matter greatly.
The value and support offered to families by the Coronial Legal Assistance Service is also
provided to the coronial system and to referral organisations. This should be considered a
further advantage of the Service, removing role conflict for many of the professionals, and
offering structure for the families within a legal process.
Improvements and gaps in the current service (Qs 22, 23)
The majority of respondents had clear and similar ideas about the gaps and the identified
areas of improvement: the need for more funding and a clearer understanding of the Coronial
Legal Assistance Service and referral processes; the lack of emotional and psychological
support for families, witnesses and staff; and, the provision of a dedicated family liaison
officer attached to each coroner.
Funding (9)
The only suggestion I have in this regard is just to ensure the funding matches the
demand for the service. It is so important that any family or witness who needs
representation at an inquest are able to access that support.
More funding would be useful, particularly with respect to expenses (ie travel), incurred
to provide probono assistance.
I can’t say that I have in depth knowledge of the operation of the coronial system.
However, I think that better resourcing of the system generally would have to benefit
families involved in the coronial system.
Promotion of service and clearer referral pathways (8)
Perhaps another improvement is just around the way in which we connect families and
witnesses with Caxton/Townsville and whether there is more thought that could be
given to how that could be done better
Clear information provided about what the services are able to assist clients with. With
so many aspects/issues being faced by families within this process, having a clear
understanding of what the legal service can assist with will help with making
appropriate referral to that service.
It would be beneficial to include [providers] legal details in our brochure or
correspondence to the families.
38
Access to counselling and emotional support for families, witnesses and staff (14)
There is essentially no emotional support for families as soon as the autopsy has been
completed. Generally the NOK inability to process their grief etc is what causes the level
of anger, which then results in them wanting to engage a lawyer etc. I suspect that if
NOK received extensive support through the coronial process, including assistance to
deal with their guilt, this would lessen the burden on the legal system
Families and witnesses need CONSIDERABLE social and emotional support during their
involvement with the coronial jurisdiction… [CCQ Staff] receive ZERO support to perform
that part of our role and it is incredibly difficult and results in poor outcomes for both
those families and witnesses and for the staff themselves. We are in GREAT need of
some sort of psychological /social support, both for the families and witnesses and for
staff themselves
Counselling support for families and witnesses is important as witnesses often seem to
be neglected in the system
Longer term counselling support for bereaved families. Improved support for witnesses
at inquests especially those not legally represented /party to inquest.
Dedicated family liaison officer (9)
A dedicated family liaison officer attached to each coroner I believe is essential. It is also
beyond our expertise, so to our administrative staff that go above and beyond to support
families/witnesses.
I think a family liaison officer for each coroner would be a very positive development and
would assist to inform people about the process.
A family liaison officer – similar to our ATSILS court support officers, QPS PLOs or Hospital
Indigenous Liaison officers would greatly assist our Aboriginal and Torres Strait Islander
clients
A dedicated family liaison could work at an inquest, although in my role I do this for OIR
and during the inquest I liaise with the coroners staff. By the time the inquest or trial
happens, I have had a relationship with the family for quite a good period of time, in
some cases a number of years.
The survey reiterated similar gaps in support to that identified in the interviews: funding
commensurate with the demand; family liaison officers attached to each coroner; counselling
and emotional support for families and witnesses. However, the survey responses have
extended the need for emotional support and counselling to include staff for the first time
and they have supported our recommendation that the referral process needs clarification
and formalisation.
39
Conclusions to Part 2
The seven themes identified after the interviews with legal professionals were explored in the
survey of legal and non-legal professionals through the survey. These seven themes continue
to be relevant to organising the survey responses, with small modifications and clarifications,
as follows:
1. The Coronial Legal Assistance Service is important to support families in the coronial
jurisdiction and not all families requiring support are gaining access
2. Value is added by the Coronial Legal Assistance Service to families and to the role of
professionals within the jurisdiction
3. There is a lack of clarity and understanding about the referral process to the Coronial
Legal Assistance Service, and concerns about capacity and over-legalising the sector.
4. There is poor communication between legal, government and non-government
organisations about the coronial legal assistance service and as a consequence, survey
respondents have relied on informal networks or the service providers themselves as
to the existence of the Service, and its mandate.
5. With little guidance as to which families should be referred to the Coronial Legal
Assistance Service, and when that referral should occur, professionals with the
coronial jurisdiction appear to be acting as discretionary gate keepers to the service,
informed by those families exhibiting the greatest need.
6. There are difficulties attached to offering probono legal support in the coronial
jurisdiction, especially outside the south east, and this is exacerbated by the lack of a
dedicated contact person attached to each coroner, in the form of a family liaison
officer.
7. The vulnerability of the families and the traumatic nature of the jurisdiction means
that there is a clear need for counselling/emotional support to families and witnesses
over the life of the investigation. This should also be offered to staff as required.
40
J. Discussion and Findings - Part 3 Interviews with Family Members
The purpose of the interviews with families was to both explore the veracity of the thematic
findings provided by the interview and survey results with professionals, as well as to explore
any alternative perspectives offered by the family members, and to integrate them into our
findings and recommendations. As a general rule we will offer indicative quotes to give a
sense of the issues that have been raised, and that capture the central themes identified by
families in response to the interview questions.
Theme 1: Access to Legal Support and Range of Services
The professionals interviewed and surveyed (in part 1 and 2 of the evaluation) identified that
poor communication between and within government agencies about the availability of the
CLAS and its mandate, was affecting the ways in which families were apprised of information
and access. Their responses also demonstrated a lack of clarity about the purpose of the
service, and how families should be referred to the service, often motivated by a desire to not
overburden the CLAS and/or to not over-legalise the sector. They also indicated a clear
preference for their own discretion rather than a systematic and formal process for families.
These issues are now explored through the interviews with ten families who have accessed
CLAS at some point during the coronial investigation of their loved one.
a) Access
The family members interviewed offered an array of access points to the CLAS though very
few of them relied on a referral. It should be noted that the lack of referral to the Service
may be due to that fact that a number of the deaths occurred before the pilot project had
begun. However, this was not the case for all families and does seem to suggest that the
referral process is not clearly identifying those families who do want or need legal support
and/or are suffering the greatest trauma. Three clear processes are evident here: those who
received a referral from either the Coroners Court or the organization dealing with their
death; those who are proactive and seek legal advice themselves; those who are directed by
other legal organisations. However, even when the families gained referrals, the process
lacked clarity, with family members often taking on private legal advice prior to an inquest,
or receiving a referral more than a year after the death occurred.
• Internet search for legal advice
I had to do all the research myself. There was no, I mean, information from the coroner or
nothing easily accessed on the [coroner’s] website. I found the referral system that was just
41
almost non-existent … I had to Google it [the legal support available], speak to lawyers, all
sorts of things. (Participant 1)
• Directed by legal organisations
When my application to the Coroner was refused and I realised I would need a bit of legal
assistance, I did a bit of a ring around the prominent legal firms in [regional town], the ones
with a national profile, thinking that they would be the ones most likely to be able to help.
None of them were interested. Oh sorry, that’s not our area … At that stage, all I was wanting
was a bit of help with getting the paperwork ready to appeal to the District Court … yeah so
in desperation I contacted, I think it was the Law Society in Brisbane, and either they or one of
the law firms that I asked or that I rang, one of those recommended the [CLAS] (Participant 8).
• Referral from within the Coroners Court
I got an email originally from the coronial office suggesting that we have legal counsel
represent us at the pre-inquest conference. Then once we got there [to the pre-inquest
hearing], [counsel assisting] indicated to us that they were perfectly able to act on our behalf
… I rang [counsel assisting] after the pre-inquest hearing, and they said, look, there is a system
that now you can contact the [CLAS 1] and you can have – you might get some pro bono work
done by them. They [CLAS 1] refused it straightaway based on a – there was a conflict of
interest, I presume……I got referred to [CLAS 2], and I dealt with a fantastic lawyer. Absolutely
amazing, very, very good. (Participant 3).
• Referral from outside coronial court
It was the liaison person with [referral organisation] … not till – I don’t know how much later
it was … it was a long time later [after the death took place] (Participant 6).
b) Range of Services
The responses from professionals in interviews and surveys demonstrated that there was a
clear understanding of the range of services that could be provided by CLAS but that most
referrals occurred for more complex investigations and court proceedings. Families
interviewed indicated that staff at CLAS offered them a range of legal services including
submissions and the briefing of barristers for Inquests, burial assistance funding, and next of
kin disputes and appeals to other courts. The family members interviewed were happy with
the advice, and supportive of the service provision, but many also noted the limitations of the
support. For some this exacerbated their distress during the investigation.
42
• Support during court processes
They [CLAS lawyer] helped me with the first lot of submissions that I had to do because the
Inquest was starting but they couldn’t come to court and that would have been really helpful
if they could’ve come to court and so I had to do the next lot of submissions and it was really
stressful. It was so hard (Participant 5).
• Briefing pro-bono barristers
I was really, really grateful for [lawyer at CLAS] efforts and the [barrister] that represented us
in [regional area]. I mean, [barrister] took a week out of their life to represent us too as well,
I don’t know what compensation they got but they certainly tried; I mean, yes, they were green
but they were trying their best. That’s all you can ask for, you know (Participant 3).
I sent them [CLAS] details of my case and my problem and they invited me in for an
interview…They were very good – when they realised it was a pretty big problem that I had
going to the District Court, they were able to get the pro bono services of a barrister in
[regional area] who provided a lengthy report … It was very good what she did, I mean, she
put a lot of effort into it. [But] I disagreed with a lot of what she said (Participant 8).
• Funding and appeals
I actually went and saw [lawyer from CLAS] because I got told by the police that I’d been
removed as next of kin … well I just went into absolute meltdown … I was a mess … I just went
into panic. The [lawyer from CLAS] was the only person I could remember that could help me
with anything … I can’t remember what paperwork I filled out but I signed some paperwork to
allow [lawyer from CLAS] to act on my behalf. That was it. I’ve not had any coronial inquest
information. I’ve not had any toxicology reports, nothing. I don’t even know if it’s been
completed (Participant 7).
I tried to get some help from [CLAS], and [lawyer at CLAS] helped me with getting the funeral
assistance scheme … then after that, yes, [lawyer at CLAS] helped me to take it to the Anti-
Discrimination Commission last year … then in terms of providing information of a coroner and
that, I really didn’t receive any assistance for that. I’m still struggling with that, and I should
have been given that many, many months ago (Participant 2).
• Access to Information
The [CLAS] just got me the medical reports of [family member] … I contacted [CLAS] only in the
last probably three months. Only recently and even they [CLAS lawyer] didn’t come back to
me. I thought it’s too much for them … They finally did come back to me but they keep on
43
telling me there’s no winning. I thought its not about winning because I’ve already lost
everything so there’s no winning (Participant 10).
Theme 2: Family Perceptions of the Service Provided
a) Value of the Service
For the professionals interviewed and surveyed, a clear value was considered to be provided
by the CLAS to both the families and their own roles. Those relevant to the families included
independent advocacy and advice, technical expertise in a specialised jurisdiction, and helping
families to understand and navigate the process. This does seem to be supported by the
families interviewed, however it was not a focus of their discussions and many actually
demonstrated that their expectations of support were not matched by the provision of legal
support through the CLAS.
• Targeted advice
They gave me a lot of good advice. They were very prompt and interested and yeah they gave
me lots of good advice as to how to frame my presentation to the District court, but without
actually representing me… Yeah I had plenty of cooperation from the lawyers I spoke with and
the office staff; they were all very good. It was a good service … Yeah, I still keep in touch. I’ll
be letting them know – once I get an answer to my appeal. I’ll be keeping them in the loop.
(Participant 8)
I: What did you think was most useful or helpful about the services that were provided to you?
The guidance, what I should do, the problem is I could not do it in the state I was in, that’s the
problem … that’s the missing link (Participant 2)
• Respect and Support
Yeah look I feel this time that I’m being treated as a person, as an important person. Before I
didn’t if that makes sense … but my thoughts or questions might be stupid in the legal sense
but they’re still relevant to me (Participant 9).
They [CLAS lawyer] were fantastic. Yeah, they asked me – what was my concerns and I
certainly briefed them. Their [CLAS lawyer] level of contact and – I hesitate to use the word,
caring, but they sounded like a very caring person but – how do I put it; their level of
engagement with me was fantastic. If I sent a message or request through to them, they
would just chew it up and just digest the whole thing and understand completely what – where
to go and what to do with it. Yeah, they were really, really good (Participant 3)
44
b) Limitations of the Service
As noted above, many of the family respondents in the interview were more focused on the
limitations of the service than their value. This is in stark contrast to the feedback provided
by the professionals who were overwhelmingly supportive of CLAS, while noting the gaps in
the sector. Families were very aware of the ways in which the funding was limiting their
access to legal support (and justice), and were frustrated with the delays. They also identified
the power imbalance between a pro-bono legal service and privately funded legal
representation in the context of a specialised jurisdiction.
• Funding imbalance in a specialised jurisdiction
Am I happy that I had representation [at the inquest]? Well, look, I guess it was good to have
a voice but for me, I think it was – I’d had to say that it was good to have the voice through a
barrister … They had just been appointed to the bar and seemed to be completely flustered by
all the big names that came up from Brisbane and Sydney….so they choked a little bit…..and
was struggling most of the time … really struggled. But that’s the truth of it. No disrespect to
them but they were well and truly out of their depth. In fact, it was a shame because, [lawyer
from CLAS] turned up and they were just the counsel assisting [the barrister] and I’d have
preferred to have [lawyer from CLAS] on the floor for me, actually. They were very switched
on and very focussed; very good (Participant 3)
• Funding limiting access to support
I: Do you know why [lawyer at CLAS] was unable to represent you?
Cost. It was cost … I said to them, well what if we paid for the airfare and your accommodation
and all that? But no, you couldn’t – they didn’t have the funding for me and mine was quite
complicated. It was a complicated case … yeah, I had to do it [represent in court] myself … I
think it was just a matter of cost. The counsel assisting, they did their questions but it wasn’t
really – I had different ones [questions] I had to do. (Participant 5)
• Families picking up the shortfall in funding
Look, I don’t think so. I mean, if – I was happy to fund the travel; that was no troubles at all.
I’m just grateful for any help we could get. But I guess if somebody really did have very – they
couldn’t afford that – I think I paid about $1500 or so to fly [lawyer from CLAS] to [regional
town] and put them up for the week in a hotel. I mean, I was willing – I was more than happy
to pay that and that’s no problems at all. But I think if people had limited resources, there
might have to – you might have to look at finding a way to possibly fund that for them
(Participant 3).
45
• Unmet expectations
Well through [CLAS] I tried to get support to try and get some sort of inquest happening for
my family member’s death, and I was told to provide this, provide that. I was just
overwhelmed … The coroner’s office in Brisbane asked me to write a letter requesting an
autopsy, an investigation. I couldn’t even come to terms to do that. Just a simple letter. We
had to engage [private lawyers], we were on disability pensions, we had to get an advance
from somewhere to pay for their fees, they told us $900 initially, it ended up over $2000. That
was a lot of money for us. This was, I would have thought, [CLAS] could have offered that
assistance. That [cost of private lawyers] was a huge impact on us … to be a little bit more
proactive and maybe facilitate the writing of letters, requests and whatever of the coroner.
Because I couldn’t … afford lawyers. We had to get Centrelink advances to fund those [private]
lawyers (Participant 2)
• Delays
I’ve been speaking with [CLAS] for months now and they haven’t even put in the appeal yet.
They said they have the matter set aside for a judge … The [CLAS lawyers] are the ones who
are going to have an email or letter drafted by the end of the week that I’ll proofread. But the
fact that [CLAS lawyer] is taking months to draft a letter to the Attorney General’s office, I
made a subconscious mistake of just taking the backseat on that. I feel that by the end of the
week if [CLAS lawyer] hasn’t actually done, actually got that draft ready and we’re on the
process, then I’m just going to contact my lawyers again…..and make my own letter
(Participant 1).
c) Gaps in the support process for families
Professionals and families agree that more counselling needs to be provided for families over
the life of the investigation, and that more funding is required if CLAS is to be able to achieve
its mandate of offering legal support to families in the coronial jurisdiction. As an extension
of this, family members requested access to Legal Aid, more face to face support in regional
locations and reciprocal relations with other states, as well as legal support from the
beginning of a coronial investigation, rather than at the scheduling of an inquest.
• Counselling
I think any coronial investigation should offer some sort of support because when I try to go
back to the original coronial counsellors they say no, we’re finished with you …. I would have
liked someone to talk to because I really don’t have anyone to talk to … there should be
something even if it’s just someone to get your vent out because I really don’t have people to
vent to. Most people don’t understand (Participant 10).
46
• Alternative avenues of funding
I would like to see Legal Aid available for people for coronial inquiries. I really don’t think that
it was going to be even if I had have had enough time. I only had three weeks notice. So I
think the notice of coronial hearings need to be much longer. Why can’t I get Legal Aid? I
mean I know they’ve clamped down so much on it … I didn’t meet the criteria for Legal Aid, a
coronial inquiry. That’s basically the bottom line. I was pretty angry about that. If I hadn’t
have got on to [CLAS] I don’t know what I would have done (Participant 9).
• Reciprocal arrangements between states
Yeah they’re [CLAS lawyer] just overworked….more funding please and the other thing is see
if you can get some reciprocal arrangements interstate for people like us … that would speed
the process up enormously and in fact would use less resources because there’s none of this
wasting time going backwards and forwards and long phone calls instead of both looking at
the screen together and saying oh let’s change that word and knock this letter into shape quick
smart (Participant 6).
• Support for the entire investigation
I think it would’ve been good if I got helped – a bit of guidance right from the beginning
because I was sort of paddling my own canoe for two years before I got [access to CLAS] … I
just think more money and more support from the beginning [of coronial process] would be
good (Participant 5).
• Regional support/face to face support
I’m in [regional area], if there was something a bit more locally based rather than having to
rant through phone line to somebody we never even see. It’s different face to face as against
on the end of a phone line, because that way hopefully the other part can appreciate through
our body language and whatever what we’re going through. Because a voice is only just one
aspect of it (Participant 2).
Theme 3: Problems with the coronial process and provision of legal support
Aside from funding and counselling, the problems identified by the families tended to align
with those identified by the professionals. Families articulated their concerns about the
coronial sector in two areas: a need for better communication throughout the investigation;
support and recognition of the challenges facing families in the jurisdiction. They also
47
demonstrated the negative outcomes for families that can ensue when a coronial
investigation is protracted , there is little communication, and a lack of legal or emotional
support.
a) A need for better Communication
For the families, one point of contact would go some way to decreasing the trauma and
conflicting information evident in their discussions. By offering a clear reference point
throughout the investigation they could remain better apprised of the progress of their
investigation. This was supported by the professionals who suggested that a key
improvement for the sector would be the provision of a family liaison officer attached to each
coroner in the state. We have noted in Part 1 of the evaluation, that this would bring the
coronial jurisdiction into line with other organisations in Queensland, such as the Office of
Industrial Relations.
• One point of contact
The most emotional thing is having to relive it [details of the death] dozens and dozens of time
to people over the phone or in meetings. As I said, this is two years going on. I was hoping
after 12months that there would be an unveiling, and that would be the end of it … the
moment I want to try and put it all aside and say forget it, she’s [family member] never coming
back, let’s move on with my life, I get contacted by the Coroner or the Attorney General
(Participant 1).
I rang [coronial officer 1] but I don’t like to hassle them because I don’t want them hating me
… So I leave it – but I do get to the point where I feel like somethings going to happen so I ring.
About every 3 months I’ve been ringing to see what’s happened. No-one rings me. However
[coronial officer 1] said they have finished with me now, it’s gone to [coronial officer 2]. First
it was [coronial officer 2] that I rang and then I rang again and now its [coronial officer 2] and
someone else. They’re the investigators or something like that. I’m not sure exactly. [Coronial
officer 1] has always been very droll but then when I rang probably 9 months ago or something
they were almost like excited for me, ‘it’s finally moving’. It’s like ok where? What’s that
mean? I don’t know because I’m not part of the system I don’t know how long and I was told
by [coronial counsellor] originally this was going to be a marathon (Participant 10).
• Regular Feedback
Communication and honesty with the actual process times and the process that needs to
happen. I wouldn’t have ever dreamed in my wildest dreams would I be still waiting nearly
three years down the track to find out how my [family member] died … Government process
and things take time because there’s lots of things that you have to do. I understand that.
48
Just to be open and honest with the length of time so people aren’t left waiting…..you could
set up an automatic email process that every month you can send an email – like it just
automatically generates an email to say that you’ve moved up – you’re now three hundred
and thirty thousandth in the list….be able to see yourself moving down the track. I mean if
people know [where they are in the line]…you get frustrated but you’ll still sit there and wait.
Yeah something to say that the case is closed. I don’t have to sit there and think, well okay
am I going to be called up to speak in a courtroom….am I going to have to go to court? Am I
going to have to defend myself? Am I going to have to – am I going to be accused of things?
(Participant 7)
• Transparency over time frames
When you go to the Attorney General’s website or the coroner’s website, there’s just no clear
information of how long it takes for an investigation or anything. It’s almost taken the
coroner, it’s taken them over 18months to come back with an inconclusive (Participant 1).
b) Support and Recognition
When families are brought into the coronial jurisdiction, they have little understanding of the
process and are in a traumatic and grief-stricken state of mind. We know that this decreases
their capacity to process and remember information. For this reason, processes need to be
clear and easily accessible. Families spoke of unclear and protracted processes and delays,
with little to no information from the Coroner’s Office and a reactive approach to accessing
information while dealing with a challenging bureaucratic process. Many of these family
members also demonstrated amazing tenacity, continuing to challenge the circumstances of
their family members deaths over many years.
• Unclear coronial processes
You’re dealing with people in really shitty circumstances. They need to start right at the base
and go, right okay, well we need to organise for these people – anybody dealing with a death;
it doesn’t matter whether it’s intentional or accident or whatever. A piece of paper that states
what it is that you have to do. Okay, well not that – you’ve got to do this. You’ve got to sort
the funeral home. You’ve got to go and sort this and this and this. Because if you’ve never
ever dealt with anything like that you’ve just got no idea … All these processes – if I had have
had a piece of paper that stated on it what I needed to do … so yeah communication would be
the biggest – have a piece of paper that states the process (Participant 7).
49
• Bureaucratic responses to requests for information
As soon as I started to push back with them (coronial system) and say look, this is taking too
long, it needs to be investigated by professionals, there was always suggestion that you’re
welcome to do whatever you like, but this is the procedures we follow and this is the webpage
and this is the reference to the, you know, the government act that we follow. It was like
pulling teeth out of a shark that has 1000 teeth. Should’ve been easy, but it was near
impossible (Participant 1).
• The effort required to challenge the system
Because they [parties involved] were covering up, I just kept writing letters about how terrible
[family member’s] treatment was and then they decided they’d have an inquest … but that
was [date], so I did the first PIC hearing myself and then they released the brief of evidence. I
just went through it and I just collated all the really important things and sent a letter of – I
probably sent two letters off. So then the second PIC hearing, it all started getting delayed
then because then they’d ask for more information from different people because things were
not adding up. So then I just kept doing that because even the autopsy report, it said they were
dead for four hours before we found them and all this wrong information … so yeah it was all
very stressful … I think we found out in early [date] that there would be an inquest but if I
hadn’t pushed it from the beginning, there wouldn’t have been because they thought
everything went well [based on reports completed on the death] (Participant 5)
• Dealing with a reactive jurisdiction
I got no instruction or assistance at all from the [Coroner] or the State Coroner as to what my
options [for legal support] were……as far as technical assistance goes, I got absolutely nothing,
from memory, from either the [Coroner] or the State Coroner. Every time – I wasn’t aware of
what my rights were at this stage in demanding access to information and so on. It was only
when I requested information such as an expert medical reviewer’s report that was
immediately sent to me. There was no problem when I asked for things. But nothing was
offered……..nothing – I didn’t get any offers of – no advice, I’ll put it to you that way, no advice
from the [Coroner] or from the State Coroner (Participant 8).
• The need for legal knowledge for a successful outcome
A coronial investigation is supposed to be getting to the nuts and bolts of why they died … but
these things were never brought up in court … none of this stuff’s ever been investigated. Oh
no, you haven’t got a case, mate, but hey, we enjoyed your victim impact statement, your –
the one page scrawled note that said how much you missed your [family member] … if you
50
don’t articulate the way forward and you don’t understand remotely the way the legal process
works, you’re never going to get any glory unless you can put it together. (Participant 4).
c) The outcome
Some of the more difficult and challenging responses from families were when they identified
the human cost of the death of their family member and the role of the coronial jurisdiction
in exacerbating that harm. In these families the trauma and harm most often manifested
itself through suspicion and a lack of trust in the coronial investigation and its outcomes.
• Lack of trust in the process
I don’t know what to expect [in the coronial process] and because I’m kept so in the dark I’m
allowed to make those assumptions that I don’t trust them because I’m not getting any
feedback. Give me a ballpark figure of how long this is going to take. We can’t. Is it going to
be a year? Is it going to be 10 years? … I don’t know if they’ll [coroner’s court] even tell me if
there’s going to be even anything or any findings. I’m so scared that they’ll just be – I’ll miss
the date because I’m kept in the dark. No one has rung me for a long time. I ring the coroner’s.
They never ring me (Participant 10).
• Disquiet over investigations
It’s just a shame I’ve got to go through all that trouble and then I think how many others
[deaths] have been covered up like this … because I didn’t trust them doing their own autopsy,
they might have covered things up, who knows. I’m not saying they would, but I just don’t
trust [the government department] – it’s like a murderer asking themselves to investigate
themselves instead of the police investigating it (Participant 2).
• Suspicion over lack of support
You just think, it depends on what there is to hide, who’s involved and, even like with [CLAS],
oh, we [CLAS] can’t do it [take on case] because it’s a conflict of interest. Well what is a conflict
of interest from a community legal centre with me versus the State of Queensland? You [legal
services] won’t get funding, is that the conflict of interest? (Participant 4).
• Cynicism about the process
There are some good things with the service [CLAS], but they [coronial system] are doing less
than half of what would’ve been considered morally or ethically required, and their late
responses, their fobbing me off on the phone, their email from the coroner saying look, we’re
not going to answer your phone calls anymore. We’ll send you an email once we’ve finished
51
our investigation. That was like a year ago. It’s just, it’s [coronial system] it’s really broken
(Participant 1).
• Realistic expectations of people suffering grief and loss
You’re dealing with people who just – their world has crumbled. You can’t expect common
sense out of them because you’re not going to get it. You can’t expect people to know
processes that have never had anything to do – it would be like someone telling me to go and
be a brain surgeon … I’ve got no idea [what to do] (Participant 7).
Conclusions to Part 3
The seven themes identified after the analysis of parts 1 and 2 of the evaluation were also
utilised as a starting point for the analysis of interviews with family members. These seven
themes continue to be relevant to organising the interviews with family members, with small
modifications and clarifications. However, three further themes were also identified, as
follows:
1. The Coronial Legal Assistance Service is important to support families in the coronial
jurisdiction but not all families requiring support are gaining access and the limitations
of the support is exacerbating the distress of some families during the investigation
2. Value is added by the Coronial Legal Assistance Service to families but their
expectations of support are not always matched by the provision of legal support
through the Coronial Legal Assistance Service.
3. There is a lack of clarity and understanding about the referral process to the Coronial
Legal Assistance Service, with very few of the family members interviewed relying on
a referral to the Coronial Legal Assistance Service.
4. There is poor communication between legal, government and non-government
organisations about the coronial legal assistance service and as a consequence,
many professionals have relied on informal networks or the service providers
themselves as to the existence of the Service, and its mandate.
5. With little guidance as to which families should be referred to the Coronial Legal
Assistance Service, and when that referral should occur, professionals with the
coronial jurisdiction appear to be acting as discretionary gate keepers to the service,
referring only those families perceived as in the greatest need. However, interviews
with family members indicate that this discretionary referral process is not clearly
52
identifying those families who do want or need legal support and/or are suffering the
greatest trauma.
6. There are difficulties attached to offering probono legal support in the coronial
jurisdiction, especially outside the south east, and this is exacerbated by the lack of a
dedicated contact person attached to each coroner, in the form of a family liaison
officer.
7. The vulnerability of the families and the traumatic nature of the jurisdiction means
that there is a clear need for counselling/emotional support to families and witnesses
over the life of the investigation. This should also be offered to staff as required.
Further themes identified through the interviews with family members were as follows:
8. Families were very aware of the ways in which the funding was limiting their access to
legal support (and justice) and were frustrated with the delays that occurred as a
result. They identified access to Legal Aid, more face to face support in regional
locations and reciprocal relations with other states, as well as legal support from the
beginning of a coronial investigation, as useful additions to the legal support for
families.
9. The poor communication between organisations extends to families who spoke of
relying on the Coronial Legal Assistance Service due to little to no information from
the Coroner’s Office, a reactive approach to accessing information and unclear and
protracted processes and delays.
10. There is a human cost to the death of a family member and the coronial jurisdiction
can exacerbate that harm. This trauma and harm most often manifests itself through
suspicion and a lack of trust in the coronial investigation and its outcomes.
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K. Discussion and Findings - Part 4 Survey of Family Members
The purpose of this final stage of data gathering and analysis is to extend the preliminary
findings from the interviews conducted with families who had accessed the Coronial Legal
Assistance Service as well as to compare and contrast with the thematic findings from the
professionals in order to come up with a complete picture of the Coronial Legal Assistance
Service.
Quantitative results This first section describes the quantitative results gleaned from the survey, including
respondent’s demographic information, their ranking of the value and satisfaction with the
service and any questions that required a definitive yes or no answer.
a) Demographics (Q1, Q2, Q3, Q4, Q5)
Age and Gender - 13 women and 7 men responded to the survey with ages ranging from 31-
75 with the majority over 50. More specifically, 31-40 = 1; 41-50 = 2; 51-60 = 5; 61-70 = 8; 71-
80 = 3.
Education – Education ranged from Year 10 equivalent or below to postgraduate university
degree, with the majority holding a diploma or certificate. More specifically, those with a
year 10 or below education = 6; those with a diploma or certificate = 9; those with an
undergraduate degree = 1; and those with a postgraduate qualification = 3. One respondent
did not answer this question.
Cultural or Ethic group. - The vast majority of respondents (18) identified as Australian or
variations such as Caucasian or Anglo Saxon. Two respondents identified as Indigenous.
Income – Respondents were asked to identify their average household income from a range
of options. The vast majority indicated that their income was just adequate or less as follows:
very inadequate = 1; inadequate = 4; just adequate = 9; adequate = 5; very adequate = 1.
b) Awareness of and Access to the Service (Q6, Q7, Q8, Q9, Q11, Q12, Q14)
Awareness - The majority of respondents (14 of 20) were aware of the Coronial Assistance
Legal Service offered by Caxton and Townsville. All respondents (20 pf 20) accessed this legal
service at some point in the coronial investigation of their loved one.
Referral process – When families were asked how they found out about the Coronial Legal
Assistance Scheme, the majority (13 of 20) disclosed that they had been referred by the
coroners court personnel (9) or Workplace Health and Safety officers and/or Office of
Industrial Relations (3). A further family member was rung by Caxton, so we have assumed
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that their details were forwarded by the Coroners Court (1). Others came to the service in a
variety of ways: googling (2); prior knowledge of free legal advice offered by Caxton (3); advice
from a work colleague (1). One family member did not answer this question.
Range of legal services required - When families were asked to identify the range of legal
support they required from a pre-existing list, the majority of the respondents identified the
inquest (12), and requests for documents for information (9). Requests for Inquest (4) and
review of decision by coroner (5) were also identified by families as key areas for which legal
support was required.
Explanation of burial process (1) burial assistance (1), or contested burial (1) were less likely
to be identified by families. Families did however make use of the “other” category and
disclosed a range of further legal needs such as: issues about next of kin (1), explanations of
coronial findings and autopsy reports (1); review of decision of WHS prosecutor (1);
counselling service offered by Caxton (1); legal advice in writing submissions to government
ministers (1) and advice about dealing with the media (1).
Access – Families were asked when in the process they accessed legal support. Ten families
indicated that they only accessed legal support in the weeks preceding the inquest, and a
further two accessed this support 12 months after the death of their loved one.
c) Evaluation of the Service (Q10, Q15, Q16)
Usefulness of the Service – Families were asked to rate the usefulness of the service. The
majority rated the service very highly, though there were some families who ranked the
service quite poorly:
10/10 (9); 9/10 (4); 8/10 (1); 7/10 (2); 6/10 (1); 4/10 (1); 2/10 (1); and one was not satisfied
at all, ranking the service 0/10.
This would align with the feedback from families about the adequacy of the service, where
five family members ranked the service as not adequate.
Satisfaction with the Service - Families were asked to comment on their satisfaction with the
support they received from the coronial legal assistance service. Again the majority rated the
service very highly, with some again ranking the service quite poorly.
10/10 (10); 9/10 (5); 8/10 (1); 7/10 (1); 5/10 (1); 4/10 (1); 2/10 (1); and one was not satisfied
at all, ranking the service 0/10.
d) Preliminary conclusions
Demographics: the majority of respondents had low education and income, making them
suitable beneficiaries of the Community Legal Sector.
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Awareness and Access: the majority of families accessed the Coronial Legal Assistance Service
through a referral from the Coroner’s court or associated organisations once they were
informed that an inquest was occurring into the death of their loved one. Six family members
accessed the service without a referral.
The majority of families used the service to support them through the inquest but many also
required considerable support to access documents or information from the Coroner’s court.
This aligns with previous findings from both families and professionals, indicating that the
Inquest is the main “pain point” in the need for legal support, but that access to information
about the investigation was rarely forthcoming without request. Changes to the organisation
and training of coronial personnel to enable proactive communication and documents to be
accessed directly from the Coroner’s Court rather than via the Coronial Legal Assistance
Service should alleviate some of this work.
Value: The Coronial Legal Assistance Service was rated highly by the majority of families.
However it was not rated as highly as the professionals rated it and some families surveyed
indicated a clear dissatisfaction with the Service.
These preliminary conclusions will now be explored in detail through the exploratory
questions within the survey which sought more information from respondents about these
issues.
Qualitative results
The discussion here will explore the survey results in more detail, reflecting on the issues
raised in the quantitative results noted above as well as with the interviews that preceded
the survey, comparing and contrasting where appropriate. This analysis is thematic rather
than descriptive, and so questions have been conflated to identify the key issues raised across
questions. The conflated analysis is indicated through the identification of the relevant
questions informing the theme.
Value provided by the service (Q17)
One question in the survey asked families to identify what worked well about the service
received. Interestingly, emotional support and a supportive environment was valued as much
if not more so than the legal support and assistance, indicating that the way in which the legal
support is offered is crucial to a positive outcome from the families.
a) Emotional support (8)
Calm and supportive environment and very professional … I leant on [legal service provider]
quite heavily at this time and they were really wonderful in supporting me.
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The high level of emotional support we were given by [legal service provider] but specifically
[legal officer]
Communication, being represented by competent caring professionals, could not have
coped without their support.
Compassion shown to us as a family
This program was/is a lifeline. Having access to legal and counselling by such a professional
switched on team was such a bonus for me and helped me get though dark days as I
navigated the role of executor, a fractured family, and the coronial process
b) Availability and a Supportive environment (3)
[Legal officer] was always there to explain every little piece of evidence or material, through
the whole process. She happily organised days for our family to go into the office in person to
explain things over if we did not understand correctly. I thought it was fantastic that [legal
service provider] was able to access the transcripts from the inquest free of charge.
The staff members of the legal team were very efficient and were always available if I needed
to ask a question or if I needed anything explained to me
c) Explanation of the system and process (2)
Explanation of Coronial Reports and Autopsy reports
The coronial process was explained to me
d) Provision of Legal advice (6)
Getting most of the relevant reports pertaining to my husband's death, very revealing.
Advice and representation
While we didn't get an inquest, we still received very good service and advice.
Correct documentation collected. Medical records and death records collected. Legal support
to claim negligence was very well communicated for all parties involved in the legal process.
Improvements and gaps in the current service (Qs 18, 19)
The majority of families offered feedback about both the Coronial Legal Assistance Service
and the coronial system in general. Concerns about the legal service provided focused
predominantly on resourcing, while the issues raised with respect to the Coroner’s system
centred on communication, lack of emotional support, the huge delays in finalising
investigations and the lack of alternative avenues of legal support.
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a) Legal Service
The families clearly identified that the legal support was constrained by resources and that it
was this issue predominantly that led to their concerns, which ranged from staffing
changeovers, to a lack of timely responses and inconsistency. The lack of access in regional
centres was also noted as was the need for clearer communication during the inquest.
• Lack of timely support
I felt the service was only doing the bear minimum, not actually advocating or taking on
representation of the family's side of considerations. Often I would not get a response back
from a call for several days or more, but on 3 occasions there was no response at all. Prompt
response is important to people who are often feeling in the dark.
• Lack of consistent support
Different lawyers at different times did not work well and having to go through the death and
the process to different lawyers was stressful. Having one lawyer for your case through the
whole case would be beneficial if possible.
I felt that the staff were too busy, on initial contact the appointed solicitor changed, which led
to a delay in the support being offered.
• Lack of resourcing
I felt there was a willingness of support, however the solicitor appeared to have too many
commitments to allow a fluid, timely level of support.
I would say the ability to commit resources to allow real value to a family. I think it is a resource
issue, I am not suggesting the solicitors do not care.
• Priority of funding
There's a huge gap in the expenditure of the Qld government departments on legal advice and
representation to defend their services and the limited expenditure on family representation
and case building. They ought to be even if this is ever to be trusted as an independent and
neutral process.
• Support in the Inquest
I think it’s important that the counsel who represents the families in an inquest, through (legal
service provider] ask the families their concerns toward the end of the coronial inquest, and
listen to their needs and wants during the coronial inquest, more specifically if the family
would like something answered that has yet to be answered of the other party.
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• Lack of regional support
I guess that the distance between myself and [legal service provider] could have played a vital
part in our professional relationship. It was hard not to know the people to whom I was
speaking until the first day of the inquest
b) Coronial System
The families identified issues that have already been raised in previous reports and focused
on the lengthy delays in finalising investigations, and the lack of communication with families
about the investigation and its progress. Issues not previously canvassed included the
psychological distress created by the delays, the need for specialised training for police, and
making legal spaces more culturally appropriate.
• Time (9)
Keeping families informed of the processes required and the expected length of time even if it
is a stupid amount of time like 3 years
Again if realistic time frames can be provided to the families. Appreciate that it can be difficult
at times but would much rather be advised of the delays than be kept advised with inaccurate
time frames.
The only difficulty is how long the wait period is for the Qld Coroner to look at a case. For us
over two years, however that is outside the legal services control.
The horrendous amount of time it takes to hand down an [external agency] report, and the
time it took to receive a Coroner's Report, 2 years 5 months in our case.
• Communication (8)
I also feel that there needs to be constant contact with families, even if there is nothing to
report on. I think making that contact to even just let families know that there is no update,
can help the families feel like we have not been forgotten during the long and isolating
process.
The coronial journey is not fast moving - I knew that before my brother's accident. Perhaps
there could be quarterly reports updating clients on where things are at - even if nothing has
changed. It is important for families to feel like they are connected to this process.
• Clarification of the process (3)
I think it’s important that families understand from day one that a coroner cannot blame a
certain party for the death. I believe there are mixed understandings of the role of a coroner,
so I feel that from day one it needs to be thoroughly explained in person within the first few
contacts with families.
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• Family liaison officer
I also feel strongly about not having one liaison officer or case manager through the coroners
office. It causes significant stress when we have new people taking over, and don't know our
personal case.
• Lack of support from other organisations that provide free legal advice
You can’t go to ATSILS black on black - one aboriginal person against another aboriginal
person. I could not afford legal representation so was reliant on [legal service provider]. It
would be good to have an Indigenous person at this [legal service provider] to aid families at
this difficult time. Making it more culturally sensitive and inviting would also be helpful.
I believe that legal aid should be automatic to families who have to attend an inquest.
• Next of kin concerns (3)
As this was the second death in my family in less than 9 months, it would have been good to
have more than one coronial trained counsellor so that other immediate family members
could have had support too. I was lucky and other family members just opted to not bother as
they did not want to take a chance on what they felt was a lottery when it came to quality of
counsellors
As the father of the deceased I was only regarded as a person with an interest and not given
the status of next of kin as my son was married.
• Delays causing psychological distress
Yes, I feel that there needs to be aggressive psychological treatment available through the
coronial inquest. I am on the firm belief that prolonged time from initial investigation, to the
coronial inquest is a significant time, and certainly induces severe distress. Our family was told
we could access 'counselling' however, I believe it should be a psychologist that treats such
patients given the nature of the death in majority cases.
• Specific issues related to suicide bereavement
There is a complete lack of understanding/empathy for people who are bereaved by suicide.
This is not the fault of the legal service but of the complete inadequacy of the coronial service.
• Role of the police
The police need a team specifically supportive of families going through a coronal death
investigation. They should be able to give families a clear understanding of the investigation
over time and keep families updated about ongoing investigations.
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Conclusions to Part 4
The purpose of the survey was to clarify the findings from the interviews and to support or
extend the key themes identified. It is evident that the survey, while not large in number,
attracted thoughtful and consistent responses from the families and overwhelmingly
supported the previous thematic findings, with some minor clarifications and the addition of
a further theme, to bring the total to eleven as follows:
1. The Coronial Legal Assistance Service is important to support families in the coronial
jurisdiction. Importantly, how the legal advice is offered is as important as the legal
advice itself, with emotional support and compassion rated as key to its effectiveness.
It is also the case that not all families requiring support are gaining access and the
limitations of the support is exacerbating the distress of some families during the
investigation
2. Value is added by the Coronial Legal Assistance Service to families but their
expectations of support are not always matched by the provision of legal support
through the Coronial Legal Assistance Service. It is also not as highly regarded by
families as it is by the professionals in the jurisdiction.
3. There is a lack of clarity and understanding about the referral process to the Coronial
Legal Assistance Service, with very few of the family members interviewed relying on
a referral to the Coronial Legal Assistance Service. Referrals that do occur are primarily
for support during an inquest which is often only accessed in the weeks preceding the
court process.
4. There is poor communication between legal, government and non-government
organisations about the coronial legal assistance service and as a consequence,
many professionals have relied on informal networks or the service providers
themselves as to the existence of the Service, and its mandate.
5. With little guidance as to which families should be referred to the Coronial Legal
Assistance Service, and when that referral should occur, professionals with the
coronial jurisdiction appear to be acting as discretionary gate keepers to the service,
referring only those families perceived as in the greatest need. However, family
members indicate that this discretionary referral process is focused on the inquest and
does not clearly identifying those families who do want or need legal support and/or
are suffering the greatest trauma over the life of the investigation.
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6. There are difficulties attached to offering probono legal support in the coronial
jurisdiction, especially outside the south east, and this is exacerbated by the lack of a
dedicated contact person attached to each coroner, in the form of a family liaison
officer.
7. The vulnerability of the families and the traumatic nature of the jurisdiction means
that there is a clear need for counselling/emotional support to families (beyond next
of kin) and witnesses over the life of the investigation. This should also be offered to
staff as required. It is also important that the legal service provision is offered by
emotionally intelligent service providers in an emotionally supportive and
compassionate environment.
Further themes identified through the discussions with family members were as follows:
8. Families were very aware of the ways in which the funding was limiting their access to
legal support (and justice) and were frustrated with the delays in communication, and
staff changeovers that occurred as a result. They identified access to Legal Aid, more
face to face support in regional locations and reciprocal relations with other states, as
well as legal support from the beginning of a coronial investigation, as useful additions
to the legal support for families.
9. The poor communication between the Coroners Court and other organisations
extends to families who rely on the Coronial Legal Assistance Service due to the little
to no information coming from the Coroner’s Office, their reactive approach to
accessing information and unclear and protracted processes and delays.
10. There is a human cost to the death of a family member and the coronial jurisdiction
can exacerbate that harm. This trauma and harm most often manifests itself through
suspicion and a lack of trust in the coronial investigation – including the Coronial Legal
Assistance Service - and its outcomes.
11. The identification of a conflict of interest that precludes ATSILS from representing
more than one Indigenous family in the coronial jurisdiction means that there is a
need for more culturally appropriate legal support beyond ATSILS
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A. References
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Suicide” Social Science and Medicine 56(5), 1033-45; Boyatzis, R. (1998). Transforming qualitative information: thematic analysis and code
development. Thousand Oaks, CA: Sage; Bradford, S. and Cullen, V. (2012). Research and research methods for youth practitioners.
London: Routledge; Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology, Qualitative Research in Psychology, 3(2), pp.
787-101; Coroners Court of Queensland, Annual Report 2017-2018.
https://www.courts.qld.gov.au/__data/assets/pdf_file/0008/628064/osc-ar-2017-2018.pdf; Chapple A, Ziebland S and Hawton K, (2012)
“A Proper Fitting Explanation? Suicide Bereavement and Perceptions of the Coroner’s Verdicts” Crisis. 33(4), 230-238; Creswell, J. (2014).
Educational research: planning, conducting and evaluating quantitative and qualitative research, 5th Edition. Sydney: Pearson; Drayton D,
(2011) “Organ Retention and Bereavement: Family Counselling and the Ethics of Consultation”, Ethics and Social Welfare 5(3): 227-246;
Manheim, J. B. and Rich, R.C. (1986) Empirical Political Analysis: Research Methods in Political Science (Longman, 2nd) 135–7; Robb B and
Sullivan J, (2004) “The Past and the Present: Listening to Parental Experiences of Autopsy Practice” Grief Matters, Winter, 39-43; State
Coroners Guidelines (2013) Chapter 2: The rights and interests of family members
https://www.courts.qld.gov.au/__data/assets/pdf_file/0012/206121/osc-state-coroners-guidelines-chapter-2.pdf; Walker B, Inquiry into
Matters Arising from the Postmortem and Anatomical Examination Practices of the Institute of Forensic Medicine (New South Wales
Department of Health: North Sydney, 2001); Worrall, B. (2018) Delivering coronial services: Report 6, 2018-19. Queensland Audit office.
https://www.qao.qld.gov.au/reports-parliament/delivering-coronial-services