“In each of the three cases, a person in the care and under the control of the state had died. There cannot be any greater failing,” writes columnist JON STANHOPE.
I HAVE in the last couple of years attended three coronial inquests – two in the ACT and one in NSW.
All three inquests concerned the deaths of young Canberra men in prison. Their names are Steven Freeman, Mark O’Connor and Jonathon Hogan. Two of the deaths were in the AMC and the third was in Junee Prison.
Steven and Jonathon, both of whom were born and raised in Canberra, were Aboriginal. Jonathon died by suicide and Steven and Mark died as a result of a drug overdose; Mark from the ingestion of illicit drugs and Steven as a result of drugs prescribed by Justice Health.
I did not know any of these men, or their families, before their deaths. Attending the inquests was, nevertheless, among the saddest and most emotionally exhausting experiences of my life.
I was saddened by the death of each of these young men, all of whom were aged in their twenties when they died. Each of them had a history of substance use and addiction and overt or underlying health issues including mental illness. Each had a history of contact with the criminal justice system and of imprisonment.
It is clear that none of them had been able to take advantage of the services purportedly available within Canberra to help people with the range of issues they were living with. It is clear that society, i.e. us, had failed to meet their needs.
Sitting stiffly in a Coroners Court, hearing descriptions of the circumstance and details of their deaths, alone, desperate and locked in a cell, described in the cold, clinical and factual style that is the way of our courts, was unutterably sad to me and must have been excruciating and heart-breaking for their families.
I have not spoken in detail to any of these families about their reaction to or feelings about the inquest into their loved ones’ death.
However, my reaction was one of disappointment and frustration, admittedly of different degrees, at what I felt were lost opportunities to force or encourage the reform of systems that had clearly failed.
In each of the inquests I have attended there was, for example, stark evidence of the different arms of government – most pertinently health, justice, police and corrections – operating independently and at times in opposition to each other. In each case, a person in the care and under the control of the state had died. There cannot be any greater failing.
It is interesting in this regard to compare the difference in outcomes achieved by the external review undertaken by Philip Moss into the care of Steven Freeman while incarcerated in the AMC and the subsequent coronial inquest into his death in the prison. Philip Moss engaged closely, personally and respectfully with Steven’s mother and family and invited public submissions to his review.
The Moss report has led to substantive and enduring changes in the management and delivery of health care at the AMC. The coronial inquest into his death has resulted, so far as I am aware, in little more than simmering resentment from his family and friends.
I have recently been contacted by members of the ACT Coronial Reform Group (CRG) and have met with them. The CRG was established in 2016 by family members of people whose deaths have been the subject of a coronial inquest in the ACT and who were disappointed and/or disillusioned with both the coronial process and its outcomes.
The principal aims of the CRG are to reform the coronial process to empower families of those who are the subject of an inquest by ensuring they have an equal voice and by reforms that mandate that central features of the Coroners Act are adhered to.
In response, in large measure to the advocacy of the CRG, the ACT government convened a forum in November to discuss coronial reform. At that forum representatives of the CRG raised the full gamut of issues of concern to it and its proposals for reform.
The Justice and Community Safety Directorate subsequently circulated minutes of the forum which the CRG, in a letter in early December to Attorney-General Gordon Ramsay advised him with “considerable concern” did not reflect a range of “significant issues” raised at the forum.
Without bothering to respond and without further ado the Attorney tabled a raft of amendments to the Coroners Act that simply do not meet the expectations of the CRG and the bereaved families they represent. Nor apparently do they reflect the issues raised at the public forum held in November, which it seems, was held mainly for show.
In their letter to Attorney-General Ramsay the CRG advised him: “The families at the forum clearly explained that their experiences of the coronial process were disempowering, re-traumatising and ultimately ineffective. If JACS and the courts now design the way forward without working with families we are deeply concerned that they will merely replicate a system that meets their needs but does not meet the needs of families.”
Pray tell, Attorney, how do you propose to respond to that simple request, by grieving Canberra families, to be listened to?