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Coronial Inquests, Indigenous Suicide and the Colonial Narrative

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A Correction to this article was published on 25 August 2021

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Abstract

This article explores the over-representation of Indigenous people in suicide statistics internationally as indicative of the broader impacts of colonialism. The purpose of this discussion in a special issue of critical criminology is to widen the focus beyond criminal justice over-representation and to explore the ways in which research, social policy, and legal institutions align to transform systematically the colonial condition into a medical one. This transformation occurs in three ways. First, a lower evidentiary standard of proof for suicide determination by coroners when the victim is Indigenous is based on a coronial supposition that Indigenous Australians cannot produce a workable response to their disadvantage. Suicide is then interpreted as an understandable response, if not a reasonable one. Second, a focus by suicide researchers on individual risk factors is treated by coroners as an indication of vulnerability to suicide and ignores the collective rates of risk among Indigenous people that cannot equate with the pathological weaknesses of the individual. Third, a paternalistic approach to Indigenous people and communities in social policy positions them as failing subjects of modernity, supposedly requiring a range of government interventions to ensure Indigenous wellbeing. Based on interviews with thirty-two coroners across Australia, as well as an exploration of inquests into clusters of Indigenous suicide in Australia, we argue that differential treatment of Indigenous people in coronial practice is a contemporary feature of the Australian legal, policy, and social landscape, and that the insights are as relevant to criminal justice jurisdictions, as they are to coronial or medico-legal ones.

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  1. For a further discussion of the government program to “close the gap” and its poor evaluation after ten years of implementation, see the discussion by the Australian Human Rights Commission at: https://humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/projects/close-gap-indigenous-health.

  2. A distinction between “colonization” and “colonialism” is required when considering the long-term implications of a traumatic event. Despite its evolution throughout history, “colonization” can be defined broadly as the “single” act of settling in or taking control over a place or the process of establishing a colony (Paradies 2016). This may include assimilation, eradication of historical and cultural practices, displacement, environmental destruction, forced removal of children, genocide, and war (Paradies 2016). “Colonialism,” in turn, can be considered the practice and policy of taking over geographical places, ongoing structural dominance, and the corresponding implications of both (Paradies 2016; Wolfe 1999). It incorporates measures of elimination and coercive exploitation, such as racism and structural inequality (Wolfe 1999).

  3. At the completion of an inquest, coronial “recommendations” may be offered “on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.” These recommendations can be directed at state government or non-government organizations and implementation (or not) of these recommendations must be reported by a state government within six months of the recommendation being made (Queensland Court 2020).

  4. Despite including Canada and New Zealand in the initial research design and search matrix, data from Canada and New Zealand were not included in the final study. Canada, like Australia, does not have a national database or consensus for reporting coronial inquests in Canada. Each province has a different documentation system in place and thus needs to be searched individually. There were several difficulties faced when trying to access the data. For Manitoba, only some of the reports could be downloaded. To obtain a copy of an inquest not available online, the office of the Chief Medical Examiner in Manitoba had to be contacted. For New Brunswick, reports of coroner’s investigations were available only to the criminal justice system, the deceased’s family, insurers, and investigative agencies. Moreover, Newfoundland and Labrador did not include ethnic identifiers in the data. Furthermore, for Prince Edward Island, the coronial findings database was unable to be located and, for Quebec, all the data were in French and thus excluded. Finally, for Saskatchewan, only one relevant case (concerning two or more people) was identified. While this was not insurmountable, the fact that no province across Canada distinguished the deceased by Indigenous status meant that their data were not useful to the current study. Given that New Zealand does not have states or provinces, the Coronial Services of New Zealand website was the only database that could be used to source data. This database, however, provides findings that are deemed in the “public interest.” As a consequence, there were no significant findings available to report.

  5. It should be acknowledged that each state and territory have a different documentation system in place. There was also significant disparity in the time period of coronial inquests reported on each state/territory database. The Coroner’s Court of Western Australian website reports coronial inquests dating back to 2012, while the Coroner’s Court of Queensland website reports coronial inquests dating back to 2004. The Northern Territory Department of the Attorney-General and Justice website reports coronial inquests dating back to 1981, but for the purpose of this study, we considered only inquests from 2000 to the present. Both the Courts Administration Authority for South Australia website and the Courts Administration Authority for Australian Capital Territory website report coronial inquests dating back to 2000. The Courts Administration Authority for Victoria website reports coronial inquests dating back to 2005. The Courts Administration Authority for New South Wales website reports coronial inquests dating back to 2012, however, it also highlights “major findings” pre-2012. Finally, the Courts Administration Authority for Tasmania website reports coronial inquests dating back to 2014. This lack of consensus created several challenges, including the difficulty of identifying inquests concerning two or more people, and the lack of clear identification of indigeneity.

  6. Coroners must determine that the evidence supporting a finding of suicide has satisfied the appropriate standard of proof. In making their findings, coroners in Australia apply the civil standard of proof: the balance of probabilities but with the application of the Briginshaw principle. That principle denotes that the standard is one of “reasonable satisfaction,” taking into consideration the “seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding” (Briginshaw v Briginshaw (1938) 60 CLR 336, 362 (Dixon J)).

  7. According to Tait and colleagues (2015), there are at least fifteen different definitions of “suicide” in the literature on suicide. In addition to these fifteen, “suicide” is also defined differently by the Australian Bureau of Statistics, by the World Health Organization, and within the Operational Criteria for the Determination of Suicide. There are also various re-workings of Durkheim—definitions which include “self-sacrifice” and “refusal of medical treatment”—and definitions founded in analytic philosophy. To have no standard definition in any Coroners Acts is perhaps, therefore, not surprising, but it does add to the confusion, discretion, and inconsistency of coroners within the jurisdiction.

  8. It is little wonder that coroners diverge in their approach as there exists very little guidance as to how coroners should apply the Briginshaw standard to suicide findings in the contemporary Australian coronial system. In contrast, in the United Kingdom coroners are still bound by the criminal standard of proof when making a determination of suicide (Briginshaw v Briginshaw (1938) 60 CLR 336, 361–2 (Dixon J); Anderson v Blashki [1993] 2 VR 89, 96 (Gobbo J)). For a further discussion of this point, see Jowett, Carpenter and Tait (2018, 2019).

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Correspondence to Belinda Carpenter.

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The Coroner’s name was mistakenly identified as “Alistair Pope”. The correct name is “Alastair Hope”.

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Carpenter, B., Harris, M., Jowett, S. et al. Coronial Inquests, Indigenous Suicide and the Colonial Narrative. Crit Crim 29, 527–545 (2021). https://doi.org/10.1007/s10612-021-09578-w

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