Coroners' recommendations and the prevention of deaths in custody: a Victorian case study


Coroners have a critical role to play in the investigation and prevention of deaths in custody. Halstead uses 16 Victorian case studies to test the extent to which concerns raised by the Royal Commission into Aboriginal Deaths in Custody were echoed in coronial processing of deaths in custody cases, and whether appropriate recommendations to initiate preventive action were made. She highlights factors which skew the coronial process and draw attention away from a forward looking systemic focus which could lead to useful remedial action.


Deaths in Custody Monitoring and Research Program