Report, Motion to Take Note
Mr PERRETT (Gympie—LNP) (3.51 pm): I rise to speak on the examination of Queensland Audit Office report No. 6 of 2018-19, Delivering coronial services. The auditor examined whether agencies are effective and efficient in supporting the Coroner in investigating and helping to prevent deaths. It looked at whether the agencies provide adequate support to bereaving families; have efficient and effective processes and systems for delivering services; and plan to deliver sustainable services in the future. This is particularly important as demand will likely increase with population growth and the increasing ageing population. Already there was a 27 per cent increase in the number of deaths reported for investigation in the six years between 2011-12 and 2017-18. The auditor reported— An effective and efficient coronial system will enable a coroner to provide timely and reliable answers … Queensland’s coronial system is complex, and coroners rely on … services of multiple public sector and contracted agencies across a geographically dispersed state.
The report makes it clear that our coronial system is under stress.
The auditor found a lack of governance across the coronial system; that responsibilities were spread across three agencies with competing priorities; that no one agency is accountable for managing an investigation from start to finish; that this has impacted their efficiency and effectiveness; and that case management practices tend to be reactive rather than proactive. Consequently, the backlog of coronial cases 24 months or older is increasing, investigations are being delayed and some families are poorly informed. The period the auditor examined recorded an increase from seven per cent to 16 per cent in cases older than two years, and 522 recommendations were issued to state government agencies.
Coroners are there to resolve matters, find clarity and provide hope and trust that situations which led to a death do not occur again. Coroners are responsible for investigating deaths that happen under certain prescribed circumstances. Their primary obligation is to make formal findings in respect of the death including the circumstances and cause of death—issues such as date, place, medical cause and circumstance. Their role is to find out what happened, not to lay charges, point the finger or lay blame.
However, they do have the important power to make recommendations.
The auditor looked at more efficiently integrating the services and agencies which support the Coroner. Other government departments and agencies should also have an ethical responsibility to do everything possible to ensure we do not revisit tragic workplace situations. Government agencies should assist the Coroner, not make it harder. Their behaviour should be the exemplar of cooperation, not obstruction.
Last year the Coroner investigated the loss of eight fishermen’s lives from the sinking of the vessels Cassandra in April 2016 and Dianne in October 2017. It is a reflection of the workload that this was not investigated until March last year—almost two years after the sinking of the Cassandra and 17 months after the Dianne. The Coroner reported—
The circumstances are a significant concern as eighteen commercial fishermen have died at sea in the waters off Queensland in the years since 2004.
This investigation is still pertinent as only this week a Tin Can Bay deckhand went missing at sea.
As I said earlier, it is vital that government departments should assist the Coroner wherever possible. Unfortunately, that was not the case during the investigation. The Coroner said— I cannot let the inquest pass without making comment critical of the DAF. Not only did that Department adopt an approach which was in my view simply bureaucratic obstruction in an attempt to ‘defend’ their then position, the worst aspect was that it took until sometime during the inquest before any concession was made by the Department that not only was this function of the VMS currently available, and that it already exists, but that it had existed for quite some time.
Fisheries Queensland was caught red-handed in claiming that vessel monitoring systems would be used for safety on commercial fishing boats. It never activated the feature and had sold it to the industry under the pretence that the devices would be used to monitor their vessels and alert authorities in cases of emergencies. The Coroner said—
I cannot find any valid reason why it cannot be implemented, and accordingly I Recommend (as have coroners before me) that the Department of Agriculture & Fisheries implement real-time monitoring of the VMS tracking or ‘failure to poll’ function of the system …
In the interests of all Queenslanders we need to address the structural and systemic issues identified in our stressed coronial system. Doing nothing will further erode its ability to provide services beyond the short term.