First Nations families failed by Coroners Court

In a shocking, recent example of the treatment First Nations people often receive in the Coroners Court, family members were turned away from a West Australian courtroom for wearing shirts with their loved ones’ faces. Later, they were told to sit in the second row so as not to “intimidate witnesses”.

National Justice Project director George Newhouse AM said he has had “many experiences” where similar incidents occurred.

“The Coroners Court is a coronial artefact. It’s one of the oldest jurisdictions in the Commonwealth world, so to expect it to respond in a positive way to First Nations people and provide culturally safe and trauma-informed practices is very difficult.

“There is a lot that needs to be done,” Newhouse said during a session at the 2026 International Access to Justice Forum.

In a 2020 report, titled The Experience of Aboriginal and Torres Strait Islander Participants in Australia’s Coronial Inquest System, Newhouse and colleagues Daniel Ghezelbash and Alison Whittaker detailed several other examples where coroners, and the system, mistreated First Nations families.

In the inquest into the death of Robert Bropho, the coroner suggested that if there were substance to his daughter’s claim that medical care had been denied, “they would have been investigated and the results of the investigations attached to the Department’s offender management file”.

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The same coroner made the “demeaning finding” that Bropho had “cried wolf [to] elicit attention from his family”.

During the inquest for a woman who died from an untreated infection in her broken ribs – allegedly caused by a family violence incident – her family’s single senior counsel and two lawyers faced the 11 lawyers acting for 29 interested persons.

In 2018, a mother told media she felt her parenting skills and her child’s care had been “on trial” during the inquiry.

Following the recent inquest into the death of proud Yuin man Gregory Merriman, his brother told media that the justice he wanted done “wasn’t handed down”. While acknowledging the systemic issues of Indigenous incarceration, the coroner determined Merriman’s death was due to natural causes.

Newhouse said the system “does not like reflecting on itself”.

“It does not like acknowledging racism. It will identify rotten eggs, but to say the health system provides a discriminatory form of care, well, some coroners need education on that. Families, subject to what their instructions are, require us to raise some systemic issues, and some coroners push back,” he said.

Decades on: What the royal commission meant for the Coroners Court

The 1987–1991 Royal Commission into Aboriginal Deaths in Custody (RCIADIC) made 339 recommendations from its investigation of the 99 Indigenous deaths that occurred in police, prison or juvenile custody between 1980 and 1989.

In addition to improving quality of care, treatment and supervision of people in custody, the RCIADIC also made recommendations to prevent further custodial deaths, promote truth-telling and transparency, and to provide some accountability by government in regard to implementation.

The RCIADIC revealed troubling trends within the Coroners Court jurisdiction, including that some coroners resisted the classification of deaths occurring amid police pursuit as deaths in custody. Similarly, some coroners frequently omitted to examine the circumstances of arrests that led to incarceration.

The Coroners Court was the subject of 34 recommendations for reforming the system. In his 2020 report, Newhouse said many were not acted on, but most jurisdictions have implemented the key recommendations that inquests should be mandatory when an individual dies in police custody, prison, and youth detention.

Legislative changes also do not “reflect the systemic reviews” envisaged in the RCIADIC, with the report stating: “Coroners have close to absolute discretion to hold inquests referred to them where a death is not in custody or otherwise reportable”.

At the forum, Newhouse said some coroners “refuse to take submissions on the royal commission”, and a very broad variation among states and coroners “about what they will hear in terms of making recommendations and reforms”.

According to the National Deaths in Custody Program’s (NDICP) real-time dashboard, there have been 645 Indigenous deaths in custody since the royal commission. More than 17 per cent of those deaths have occurred since 1 January 2026.

The federal government used to report annually about its implementation of the recommendations, but this “dropped off” between five and 10 years ago, Newhouse said.

Newhouse said Victoria was the “leader”, followed by NSW and “individual coroners in the Northern Territory who are doing an amazing job in the face of government attacks on them”.

In 2020, the Coroners Court of Victoria introduced a practice direction to make the court a safer and more supportive place, including the establishment of an Aboriginal Liaison Unit. In 2022, the NSW State Coroner’s Protocol provided guidance to coroners during inquests into the deaths of First Nations people.

The National Justice Project said there was “still a long list of reforms that have been proposed, recommended and championed over decades, to improve the experience of First Nations families, to stop the overincarceration of First Nations people, to reduce deaths in custody, and to mitigate some of the trauma generated by inquests into First Nations deaths”.

‘Real reform’ driven by inquests

The ACT Coronial Advocates Group, representing First Nations people, said that while it was aware of some positive experiences, there were “common themes and concerns”. This included the retraumatisation, stigmatisation, disadvantage, dismissal and sidelining of the loved ones for First Nations people.

Newhouse said this “fairly sums up” what he has experienced.

“[First Nations people] come to the court grieving, traumatised, and wanting justice. What passes for justice and people’s concepts of justice are very different to what the court is going to deliver. There’s a total mismatch, and I think that’s something that really needs to be acknowledged as well,” he said.

But there have been some improvements. For instance, Newhouse said he recently watched an “absolutely amazing” live stream from the Coroners Court of Victoria. The court chooses to broadcast high-profile inquests, major findings or special public proceedings on an ad hoc basis.

Real reform was also driven by the inquest into Ms Dhu, who died in 2014 while held up for unpaid fines. As a result of the inquest, the Fines, Penalties and Infringement Notices Enforcement Amendment Bill 2019 meant West Australian police could no longer lock up people for missing payments.

Further, the death of David Dungay Jr prompted an investigation into the “dysfunctional relationship” between medical staff and prison guards at Long Bay Correctional Centre, and Newhouse said there has “not been a death since in that way”.

In July 2019, the inquest into the death of Naomi Williams was the first “to identify bias and racism in healthcare”. The court heard Williams had attended the hospital 19 times in the seven months before her death complaining of pain and nausea.

Newhouse said NSW government “radically reformed and is continuing to reform its processes” as a result.

“Positive things do happen,” Newhouse added.

What needs to change

One of the most important reforms would be a First Nations-led inquiry with its own leaders, investigators and powers to investigate the issues they want investigated, Newhouse said.

“You have to understand that the coroner doesn’t investigate deaths, the police do, and that is an immediate barrier between First Nations people and the investigation. Often it’s police who caused the death, they don’t trust police to investigate police.

“I have families right now in Alice Springs who are waiting for an inquest where the police have investigated the deaths of their loved ones. They do not trust the system,” he said.

At the conclusion of his forum session, Newhouse said First Nations loved ones need to be consulted, adding: “Culturally safe practices always begin with the family, it’s about them. What are their needs? What are they seeking?”

The Coroners Court should also ensure families get to determine what cultural safety means to them, have them engage meaningfully with the system, and give space to more than just the “grandstanding” of solicitors and barristers, he said.

“Families I meet, they want their form of justice, they want accountability, they want a voice, they want to see change. They know their loved ones’ life has been taken and they want to make sure that no other family experiences what they have,” he said.