Speak­ing for the Dead

The Monthly (Australia) - - CONTENTS - by Sarah Kras­nos­tein

What ends ques­tion­ably – or un­ex­pect­edly – ends up here amid small talk and dark suits, plas­tic cups of tepid wa­ter and the faint smell of cig­a­rettes. The Coroners Court of Vic­to­ria is brighter than ex­pected. Sun pours through cir­cu­lar sky­lights, mix­ing with the glow of light bulbs in the ceil­ing and the walls. In court­room one, where Coro­ner Caitlin English is lead­ing an in­quest into the sui­cide of a 27-year-old man, one wall is mostly win­dow.

The is­sue be­fore English to­day is not the cause of death per se, but its cir­cum­stances and whether it could have been pre­vented. The man had at­tended a pub­lic hospi­tal as a men­tal-health pa­tient just be­fore he died.

English sits alone at the bench un­der the Court’s in­signia, which bears words that are wishes we hold for our­selves and our chil­dren: Peace and Pros­per­ity. Though the en­vi­ron­ment is pleas­ant – all soft green fab­rics and honey-coloured wood – the work to­day seems ex­cru­ci­at­ing. It is the work of all court­rooms: a striv­ing to rec­on­cile gross dis­e­qui­lib­rium in rec­ol­lec­tions and emo­tions and con­cerns; a metic­u­lous min­ing of the par­tic­u­late el­e­ments of hu­man be­hav­iour only to sur­face with a ra­tio­nal ex­pla­na­tion that pins its hopes on ap­prox­i­ma­tion. How­ever, to­day court staff are also deal­ing with the loss of one of their col­leagues, a fe­male se­nior lawyer, to sui­cide.

A line of black blaz­ers at the bar ta­ble faces the wit­ness box. The father is giv­ing a state­ment. The room falls silent when he is asked whether he has seen his child’s au­topsy results.

Coroners in­ves­ti­gate par­tic­u­lar deaths to iden­tify their causes or cir­cum­stances. In do­ing so, they con­trib­ute to the re­duc­tion of pre­ventable deaths and the pro­mo­tion of pub­lic safety. So, while it doesn’t feel im­me­di­ately ap­par­ent on this morn­ing as the par­ents exit the court­room, un­able to re-watch the CCTV footage of their son’s fi­nal mo­ments, the coro­nial func­tion, too, is brighter – more pos­i­tive – than many would ex­pect.

“So many fam­i­lies come to court and what they are say­ing is, es­sen­tially, ‘I just don’t want this to hap­pen to an­other fam­ily’,” English says when we sit down a cou­ple of weeks later. To as­sist in this func­tion, the Court es­tab­lished the Coroners Pre­ven­tion Unit, a spe­cial­ist ser­vice that col­lects and uses data to iden­tify op­por­tu­ni­ties to im­prove pub­lic health and safety.

This work is what at­tracted English, who was ap­pointed as a mag­is­trate in 2000, to the Court four years ago.

“I’ve al­ways had an in­ter­est in pub­lic pol­icy, and the coroners’ ju­ris­dic­tion rep­re­sents that real in­ter­sec­tion of law and pol­icy. You might be deal­ing with an in­di­vid­ual case, but be­cause the rec­om­men­da­tions power is about re­duc­ing the num­ber of pre­ventable deaths it means you can have a far greater sys­temic ef­fect.”

There are ap­prox­i­mately 6000 re­portable deaths a year in Vic­to­ria. These in­clude deaths in state cus­tody or care; deaths that ap­pear “un­ex­pected, un­nat­u­ral or vi­o­lent”; deaths that oc­cur dur­ing or fol­low­ing a med­i­cal pro­ce­dure; and deaths where the iden­tity of the per­son is un­known. They come from hospi­tals, jails, men­tal­health in­sti­tu­tions, aged-care fa­cil­i­ties, pri­vate homes and pub­lic spa­ces, and they end up at the Vic­to­rian In­sti­tute of Foren­sic Medicine, co-lo­cated with the Coroners Court, as cases for con­sid­er­a­tion. The cases are dis­trib­uted among 11 coroners who, af­ter con­sid­er­ing the ad­vice of a foren­sic pathol­o­gist, make or­ders about whether an au­topsy is nec­es­sary.

“On a Mon­day you might get over 50; to­day I think there was mid 20s,” English says, fresh from per­form­ing this par­tic­u­lar duty. “They be­come the cases that we in­ves­ti­gate.”

Only 1.3 per cent of in­ves­ti­ga­tions re­sult in an in­quest. While these are manda­tory in cer­tain sit­u­a­tions, such as deaths in cus­tody, in­quests are usu­ally held when an is­sue of pub­lic im­por­tance re­quires ad­di­tional in­for­ma­tion. Un­like other court cases, the process is in­quisi­to­rial, not ad­ver­sar­ial.

“It’s not de­ter­min­ing whether some­one is neg­li­gent,” English ex­plains. “And it’s not a crim­i­nal case de­ter­min­ing whether some­one is guilty. The coro­nial process is quite dif­fer­ent – it’s fact find­ing.”

It is strik­ing: a le­gal en­vi­ron­ment of high emo­tion where con­text is priv­i­leged over cul­pa­bil­ity and used at the ser­vice of our col­lec­tive fu­ture.

The util­ity of the law lies in its clean lines. The rules that gov­ern its in­ter­nal logic en­able it to trans­fig­ure the chaos of hu­man life into clear ex­pla­na­tion. And yet, some­times, to pin­point an an­swer is sim­ply to re­state the ques­tion.

Sui­cide is the lead­ing cause of death for Aus­tralians aged be­tween 15 and 44. In 2017, 3128 Aus­tralians took their own life, an in­crease of 262 from the pre­vi­ous year. In the same year, 40 per cent of re­portable deaths in Vic­to­ria were due to nat­u­ral causes, a fur­ther third were ac­ci­den­tal, and 11 per cent were sui­cides. The fig­ures from the Vic­to­rian Sui­cide Reg­is­ter, cre­ated and man­aged by the Coroners Court, in­di­cate that over the past five years the num­ber has grad­u­ally risen.

“It’s one of the big­gest shocks of ac­tu­ally be­com­ing a coro­ner, learn­ing about sui­cide rates,” English says. “I think that gen­er­ally peo­ple aren’t aware of how the sui­cide rate is higher than the road toll, higher than the

homi­cide rate. I think an in­cred­i­bly valu­able tool that we have is the Vic­to­rian Sui­cide Reg­is­ter, that’s been de­vel­oped over a pe­riod of years to iden­tify pos­si­ble fac­tors that are causes in sui­cide.”

She says that, since join­ing the Court in 2014, she has seen an in­creas­ing num­ber of sui­cide deaths in­volv­ing metham­phetamine.

Is it al­ways clear whether a death was in­ten­tional, and what led the per­son there?

“That’s an is­sue coroners grap­ple with ev­ery sin­gle day be­cause we’re do­ing these cases ev­ery sin­gle day,” English says. “There’s an old com­mon law pre­sump­tion against sui­cide … It’s some­thing that coroners are think­ing about all the time in terms of de­ter­min­ing whether there’s suf­fi­cient ev­i­dence to sup­port a find­ing of in­tent.”

Does a ten­sion of­ten arise be­tween ac­cu­racy in the pub­lic in­ter­est and what the fam­ily may want to hear?

“I think there’s a strong ten­sion,” English replies, ex­plain­ing the im­por­tance of be­ing sen­si­tive to the fam­ily’s con­cerns about how the cause of death is cat­e­gorised and whether in­tent is found. If other ex­pla­na­tions are con­sis­tent with a lack of in­tent, the coro­ner will in­ves­ti­gate them and take them into ac­count. “Par­tic­u­larly young peo­ple. I think there’s a strong ar­gu­ment as to whether there’s an ap­pre­ci­a­tion or understanding of the con­se­quences and fi­nal­ity of some ac­tions. It’s not clear cut.”

In 2017, sui­cide re­mained the lead­ing cause of death for both In­dige­nous and non-In­dige­nous chil­dren and young peo­ple, and it ac­counted for 40 per cent of all In­dige­nous child deaths. The sui­cide rate among In­dige­nous Aus­tralians is more than dou­ble the na­tional rate. The LGBT and gen­der di­verse com­mu­nity is also dis­pro­por­tion­ately af­fected: be­yond­blue states that 81 per cent of gen­der di­verse young peo­ple who had ex­pe­ri­enced abuse and/or dis­crim­i­na­tion due to not iden­ti­fy­ing with a spe­cific gen­der had thought about sui­cide; 37 per cent had at­tempted it. This con­forms with the con­stel­la­tion of risk fac­tors iden­ti­fied by the re­search, which in­clude so­cial and emo­tional iso­la­tion, trauma and on­go­ing ex­po­sure to bul­ly­ing in ad­di­tion to phys­i­cal and men­tal ill­ness and sub­stance abuse. Re­search also in­di­cates the power of pro­tec­tive fac­tors: so­cial con­nec­tions and sup­ports, ac­cess to lo­cal health ser­vices, a sense of pur­pose and con­trol, and, per­haps, ac­cess to sto­ries of non-sui­cide al­ter­na­tives to life crises.

As en­cy­clopae­dias of lit­tle-dis­cussed but univer­sal hu­man ex­pe­ri­ence, coroners learn, in their daily work, de­tails that will re­turn in the night. English thinks for a long mo­ment when I ask about self-care. She men­tions a paint­ing course. She loves read­ing. But mostly she an­swers by speak­ing highly of the ju­di­cial coun­selling for coroners, a world first, in­sti­tuted in 2009 in re­sponse to the Court’s in­ves­ti­ga­tion into the Vic­to­rian bush­fires. Var­i­ous coun­selling ser­vices are avail­able to all staff and are be­ing in­creased.

For ju­di­cial of­fi­cers, it is a fact of the job that “sitting in court is quite iso­lat­ing, or lonely, in the sense that you’re not ac­tu­ally part of a team”. Add to that the typ­i­cal re­sponse when asked what you do for a liv­ing. “It’s a con­ver­sa­tion stop­per. It’s re­ally quite hard to go for­ward once peo­ple find out you’re a coro­ner. Maybe it’s that re­luc­tance to talk about death or not quite know­ing enough to be able to ask a ques­tion. It’s not re­ally school­yard talk with the mums.” So it is a good thing that coroners “are very col­le­giate”.

“The peo­ple are very self-se­lect­ing when you get to the Coroners Court,” says English.

“I sup­pose they’re peo­ple who are very con­scious of main­tain­ing that im­por­tant work–life bal­ance and who get on with peo­ple. I think more so than any other work en­vi­ron­ment, at the Coroners Court, where you’re look­ing at the edge of the abyss ev­ery day, the small in­ter­ac­tions of col­le­gial­ity are ex­tremely im­por­tant.”

Given the im­por­tance of col­le­gial­ity, it ap­pears that the Court finds it­self at a vul­ner­a­ble mo­ment; the state coro­ner, Judge Sara Hinchey, has stepped aside from her role as head of the Court while the Ju­di­cial Com­mis­sion hears a com­plaint about her. Mean­while, the coroners con­tinue with their work.

English says that the main qual­ity a coro­ner needs has to be love of the work.

“It’s a priv­i­lege and an hon­our. You’re speak­ing for the dead. I think it’s the motto of the Ot­towa coroners court – speak­ing for the dead to pro­tect the liv­ing.” M

Life­line: 13 11 14

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