The possibility of re-traumatisation in Australian death investigations

I am an Australian academic who has been researching the coronial investigation of deaths since 2003.  During this time I have been interested to know how and why coroners make certain decisions when they are investigating a death, decisions such as: when do coroners decide they need an invasive autopsy?; how do coroners decide if a death is a suicide or an accident?; and why do some families get heard by coroners and others don’t?  In this research I have interviewed coroners, pathologists, and police, alongside other associated personnel such as counsellors, nurses, and barristers, as well as families who have been subject to a coronial death investigation.  Most of these interviews have occurred in Australia, but I have spoken to coroners in England as well.  I have also observed many inquests in both England and Australia and have examined legislation and policy in both jurisdictions.

What have I discovered? 

Death investigations can increase the trauma and grief of a coronial death.   This re-traumatisation most often occurs when families feel that they have not been listened to by personnel investigating the death, and this can occur at any stage in the investigation. It could be at the time of notification by police when decisions must be made about the autopsy of a loved one, or it might occur in the medical investigation, if families can’t view the deceased or if burial is delayed, or it might occur prior to an inquest, when legal support is not available, or an inquest is denied.  It also can occur during the inquest when families feel that the investigation did not answer the questions that they thought most important. These feelings are consistent irrespective of how a loved one has died. 

Certain families are less likely to be heard than others in a death investigation, and these tend to be families from our most vulnerable populations.  In Australia, Indigenous people are over-represented in the coronial death investigation process, as they are more likely to die traumatically or without access to appropriate medical care.  When Indigenous families raised concerns about an invasive autopsy, they were the least likely to have that request honoured by the coroner or the pathologist. Muslim families, while not over-represented in a coronial death investigation, could also have their concerns dismissed when they raised a genuine concern about the necessity of an autopsy on their loved one. 

When a death investigation raises the suspicion of a death by suicide, families can be resistant to such a finding.  However, not all families are able to engage with the coronial system equally, with those who have lost a loved one in a custodial environment being the least likely to resist a finding of suicide. This is not helped by the difficulty of obtaining legal support in the coronial jurisdiction, which can often mean that families are the only ones not legally represented at an inquest.  This can be especially onerous for families challenging the death of a loved one in a prison or detention centre, where lack of trust is magnified, and state actors are supported by highly qualified barristers.