Family Violence and the Coroner’s Quiet Revolution

By Philip Marquet

The role of the coroner is often overlooked in human rights discourse. Public perceptions of the coroner tend to be influenced by American procedural crime dramas, where the role of “coroner” and “forensic pathologist” are virtually indistinguishable. But in recent months, the Coroners Court of Victoria (Coroners Court) has quietly led the way towards a de-politicised, evidence-based approach to reforming Victoria’s response to family violence.

In Australia, coroners primarily have legal, rather than medical, training. While coroners may attend the scene of a death, their role is limited to oversight and review, rather than hands-on investigation. Since 2008, Victoria has been at “the forefront of Australian coronial reform“, largely due to the expanded role of the coroner in promoting public health and safety.

The Coroners Act 2008 (Vic) (the Act) emphasises that the Coroners Court is an “inquisitorial court”, designed to ensure that deaths are investigated in a non-adversarial way that focuses on prevention rather than blame. The Act permits a coroner to make recommendations to any Minister, statutory authority or other entity on any matter relevant to a death. The party to whom those recommendations are directed must respond within three months, and those responses are published on the website of the Coroners Court. The coroner’s recommendations are often technical in nature (for example, recommending revised treatment guidelines for patients who present with chest pain, or the installation of road signs to indicate safe places for cyclists to cross), and are informed by collaboration with key stakeholders to ensure that they are realistically capable of implementation.

Two recent decisions by Victoria’s State Coroner, Judge Ian Gray, illustrate the power of coroners to transcend the emotion, rhetoric and politicking that often surround family violence in favour of a measured, pragmatic and evidence-based approach to reform.

The Death of Luke Batty

Luke Batty’s death in 2014 was the subject of intense media coverage. His mother, Rosie, has become a leading advocate for victims of family violence, and was named Australian of the Year for 2015. In September 2015, Judge Gray found that Luke’s death, at the hands of his father, “was preceded by years of family violence” against both Luke and his mother.

Although Judge Gray found that Luke’s death was unforeseeable (in the legal sense, which relates to whether a reasonable person would have foreseen that a certain kind of failure might cause a certain kind of harm), His Honour clearly was not suggesting that Luke’s death was inevitable, or that nothing could be done to prevent similar deaths in the future. To the contrary, His Honour made 29 recommendations that were directed to the Victorian Attorney-General, the Family Law Council, Victoria Police, the Victorian Department of Health and Human Services, the Magistrates’ Court of Victoria, and a number that were simply directed to the State of Victoria in general. The message was clear – the problem of family violence is not intractable. Here are at least 29 ways to make a difference.

The Death of Sargun Ragi

Sargun Ragi was born in India, and came to Australia shortly after entering into an arranged marriage with an Indian-born Australian citizen, Avjit Singh. Thereafter, Singh began locking Ragi in their house, with only basic necessities, while he went to work. He coerced her to have sex with him by threatening to divorce or deport her. After escaping through an unlocked window, Ragi left the relationship with the help of friends and neighbours, and made contact with police, courts and a number of family violence support services.

Despite this, according to Judge Gray’s findings handed down in October 2015, Singh was “determined to exact vengeance” and hired a private investigator to track down Ragi. He eventually broke into her new house, stabbed her repeatedly in a prolonged attack throughout multiple rooms, poured petrol over her and lit her on fire. Both Ragi and Singh died in the fire.

Judge Gray found that Singh was “motivated by a culturally entrenched, patriarchal, male-entitlement attitude”. Importantly, although Ragi had done everything possible to protect herself, no formal intervention had ever been directed at educating Singh about family violence or changing his behaviour. His Honour recommended that Victoria consider developing “education programs for culturally and linguistically diverse men who are perpetrators of family violence.” Currently, Victorian magistrates only have the power to direct men to complete a behaviour change program in a pilot program that operates in two of the 54 Magistrates’ Courts in Victoria. This was the first time such a recommendation had been made by a Victorian coroner.

Do Coronial Recommendations Work?

While awareness-raising and advocacy is an important part of the systemic response to family violence, the true measure of success is implementation – have such recommendations actually been acted upon by those with the power to make a difference? Do the recommendations make real progress towards eliminating the persistent, entrenched gender inequalities which lie at the heart of family violence?

While time will tell the outcome of evidence-based family violence inquiries (including, of course, the Victorian Royal Commission), some research suggests that coroners’ recommendations generally have a genuine impact on the causes of preventable death. A 2014 study by The University of Melbourne found that 37 per cent of coroners’ recommendations were implemented by the organisations to which they were directed, while a further 36 per cent were “supplanted” (that is, not implemented because the organisation itself had already taken action to address the particular issue). Additionally, 27 per cent of recommendations were rejected, perhaps due to the cost or feasibility of implementing them, although this issue is yet to be more fully explored.

But what is clear is that coroners have the potential to be powerful advocates for family violence reform. Their role as independent judicial officers, with broad powers to inquire into the causes of death, backed by an investigative unit that prioritises an evidence-based, pragmatic approach to reform, gives them an almost unrivalled ability to drive institutional changer – a kind of “soft law” which nevertheless has coercive force.

Even if not all of the Coroner’s recommendations in the Batty and Ragi cases are taken up, institutions are now forced to at least consider them. In considering whether to implement those recommendations, the question must surely be this: if not, why not?

Philip Marquet is a commercial lawyer in Melbourne.

Feature Image: Rosie Batty. Flickr