Senate Inquiry, Hearing Program 4th Nov 2011

[Kharon]

Coroner, questions of.

Oh G' day Blackie, glad to see your posting again, early release?? Now you're out, perhaps you could give us the benefit of your opinion on a question from Sen. Fawcett to DoiT about closing the loop on Coroner recommendations.

The question was prompted by the fact that there is no open system in place to ensure that if a Coroner makes a recommendation, it is addressed, where appropriate actioned and closed off. The side bars to question bring into play issues like a public Coronial data base tied to the ATSB data and a record of CASA response and actions.

Now, there is system of sorts in play, but a little research soon reveals that (a) A WA Coroner looking at an accident may make a couple of recommendations; (b) a Qld Coroner may look at a similar accident and make recommendations; but, there is no correlation of information, no way to ensure that all recommendations have been examined or to see what has been done to prevent a reoccurrence.

1) Unless you personally get a transcript there is no way to see the Coroners recommendations.

2) Unless you personally monitor CASA actions on those recommendations, there is no way to determine exactly what has been done, why, by whom or the method used.

3) Unless you are a mind reader there is no information available from the ATSB on any of it.

So, to explain fully; Coroners recommendations can and do disappear (like bubbles in the bath), promised changes to legislation accommodating Coronial recommendations does not appear, safety actions don't occur and, no one knows. Then there is the notion that a Coroner may have based some part of a decision against the "promise" of changes; once again who would know.

There is some bloody good research (Thanks PAIN_Net) on this out there now and the results are grim. Clearly the Senator would love some answers. So Blackie, how about it; perhaps you could once again enlighten us mere mortals here on Pprune with your usual insight, wit and eloquence.