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COMMUNITY AFFAIRS REFERENCES COMMITTEE
31/03/2010
Suicide in Australia

CHAIR —Welcome. Thank you very much for making the time to come along today.

Mr Hope —Thank you for inviting me.

CHAIR —I understand that you have been given information on parliamentary privilege and the protection of witnesses and evidence. I invite you to make an opening statement and then we will ask you some questions.

Mr Hope —As the State Coroner of Western Australia, I am responsible for the investigation of all sudden deaths. In that capacity our court investigates about 300 deaths by suicide each year. I was appointed the State Coroner in 1996, so for the 14 years that I have been responsible for the investigation of suicide deaths there have been between about 200 and a bit over 300 suicides every year. Over the past 13 years I would have read about 2,000 files relating to suicide deaths, I have seen the photographs of over a thousand bodies and I have read the suicide notes, where there were notes, of all of those people. So in my capacity as State Coroner I am painfully aware of the immense personal, social and financial cost of suicide in Australia.

In talking about those numbers, it does surprise me sometimes how consistent the numbers seem to be, which is interesting when every individual case seems so completely different yet at the end of the day we seem to have very much the same sort of numbers. That suggests to me that underlying problems that are constant are the drivers for the total number of suicides even though with individual cases intervention programs may be able to save particular persons at risk. In my capacity I expect to see a new mortuary admission form, which is the form that goes with a body to the mortuary, every working day. Today we have six bodies in the mortuary. Four of them are clear suicides deaths and one is a possible suicide death with a medication overdose. That has happened since I came here yesterday. Of the categories of sudden death we investigate, suicide constitutes the largest number. I am sure you are aware that suicide deaths, for example, exceed motor vehicle and motor traffic deaths in Western Australia, as they do elsewhere. Our figures in respect of motor vehicle deaths are that we usually have about 220, which again interestingly seem to be remarkably consistent although the cases are so different.

I have brought along a breakdown of our recent suicide deaths. According to our statistics, in 2008 there were about 310 suicide deaths and in 2009 there were about 290 relatively confidently determined suicide deaths with a possible another 11. So generally there seem to be slightly over 300 per annum at the moment.

The role of the Coroner’s Court is to ensure that all reportable deaths, which includes deaths by suicide, are investigated. At the conclusion of every investigation there is a coronial determination, a determination made by a coroner, and findings are made as to the circumstances of the death. In most cases that is done on the papers and in a relatively small number of cases there is a public inquest. We only hold public inquests either in death in custody cases or where we believe there is some type of public benefit or death prevention purpose to be served by holding a public inquest.

A review over recent years reveals a general gradual increase in suicide rates. When I started in the job there were about 240 I think and now there seem to be fairly regularly over 300, as I was indicating to you earlier. WA Police investigate all the sudden deaths, including suicide deaths, on behalf of the Coroner’s Court. The evidence captured by the police is important in order to determine whether a death is a suicide and, if so, the circumstances surrounding the death. As I said before, death in custody suicide cases are inquested, but in other cases we only hold an inquest to highlight particular concerns.

I understand that you are particularly interested in the accuracy of statistics. I am not really a great fan of statistics. As a general rule I tend to find that they can be a bit rubbery. In Western Australia we have tried to be as consistent as possible. I suggest that our statistics are amongst the most reliable of the states and overseas with respect to suicide deaths. That is partly because we have a very centralised system and there are only two full-time coroners—the deputy state coroner and me.

In the country regions local magistrates act as coroners by virtue of their office and they finalise a significant number of cases, although even if the case is determined on the papers, we tend to do more and more of those. It is actually my view that the time has really come to move away from country magistrates dealing with coronial matters. I am not wishing to be critical of them when I say that, but I think the time has come for a more professional approach to coronial investigations. I particularly note with some of the files that I have been reading recently that in the country regions the quality of the investigations varies widely from one region to another. It depends very much on whether the local sergeant is interested or not. Quite often police are not all that interested in cases that are not criminal.

When compared to some of the other states, I believe our statistics are reasonably accurate. In South Australia I understand that the coroners do not make findings as to suicide. So in the NCIS where there are references to a determination of suicide that is often based on either what the police thought or what some clerk who has inputted the data believes. In Queensland they have a lot of problems because Queensland is more diverse than WA and there are a lot of country coroners. I note that Michael Barnes, the State Coroner for Queensland, has difficulty trying to get a consistent approach amongst the coroners.

When cases are not inquested there is generally less family pressure to make a finding that the death did not occur by way of suicide. If we have a public inquest, quite often there is pressure from families to find that the death is by accident or some other mechanism apart from suicide. That may be for a range of reasons. Sometimes we would have a suspicion that various family members believe that a finding of suicide might reflect adversely on their own interaction with the deceased person.

In respect of the accuracy of determination of suicide, there are obviously some cases that are very difficult to categorise anyway, particularly when there is no suicide note. Medication overdose cases are probably the most difficult, and I see quite a lot of those. Quite often the deaths are of people who are not normally compliant with their medications anyway. With those people it is very hard to know, because there may be a history of depression anyway. There is a history of noncompliance with medication and there is no suicide note, so there is a real question mark as to whether the person just took too many tablets accidentally or whether it was a deliberate suicide. Single vehicle collisions are other instances of cases that are difficult to determine.

In addition to the uncertainty based on the objective circumstances, there are grey areas in respect of intent as well. There is often a question, particularly with young children, as to whether the person really appreciated the finality of the act. For example, I saw the death of a seven-year-old child who had hanged himself, and there is a real question mark in that type of case as to whether the child appreciated that it was for ever. There are also cases where there is a grey area between recklessness and intent. I particularly remember the case of a young Aboriginal girl who had been repeatedly sexually abused. She was driving a motor vehicle in a manner which was so reckless that it would be very difficult to decide whether she wanted to die or just did not care. So sometimes intent is not clear cut either.

Dealing with our own response to cases and what happens as far as we are concerned, as I said before we attempt to identify cases where we believe we might be able to do something to prevent similar deaths in future and we attempt to hold inquests in some of those cases. One of those cases was the 2008 inquest into 22 deaths of Aboriginal people in the Kimberley. I do not know if you have a copy. I have a copy here if you want a hard copy.

CHAIR —I have a personal copy.

Mr Hope —I can certainly provide you with a copy of that inquest finding together with the statistics that I referred to earlier. In that case it appeared that a number of the deaths were caused, or contributed to, by alcohol use. The inquest was held in a context where it was noted that the suicide rates for Aboriginal people in the Kimberley had increased dramatically in 2006. In that year there was an increase in suicide rates of Aboriginal people in the Kimberley of over 100 per cent. It went up from less than 10 to over 21, which contrasted with three deaths by self-harm of non-Aboriginal people in the Kimberley—and there are more non-Aboriginal people than Aboriginal people. In that case we made some real efforts to identify the causes for the suicide beyond the immediate triggers such as relationship breakdown and so on. It was obvious that there was a very high level of distress and despair experienced by the Aboriginal people in the East Kimberley.

A striking feature of the examination of the files was the high alcohol content of a number of the deceased persons. When I pulled out the 21 deaths for 2006, in 16 of the cases the blood alcohol level taken from samples from the deceased was in excess of 0.15 per cent. So in 16 out of 21 the blood alcohol was over 0.15 per cent, and in 11 cases it was over 0.2 per cent. That is a massive alcohol level, and a lot of these people were quite young. Those cases highlighted the association between alcohol and suicide, which I suppose plays a part in releasing inhibitions and so on. In addition, the general effects of alcohol abuse and the impact on families and so on would have been a major contributor in those deaths.

The inquest also identified serious problems in respect of child protection, education, employment, housing and cannabis use. Cannabis use was a matter that was concerning me initially but was somewhat overwhelmed by the amount of evidence about alcohol. But cannabis use and its impact on mental illness, and then on suicide, is something that is becoming increasingly concerning to me. We have held a series of inquests also in respect of a number of other issues such as mental health issues and concerns as to whether mental health problems are being adequately addressed.

In respect of deaths in custody, we have to hold inquests. I have held a number of inquests where we have looked at, for example, hanging points. Obviously, while a person might be suicidal, very often the acts are impulsive. If there are obvious hanging points, that is a factor. Even after the Royal Commission into Aboriginal Deaths in Custody it seemed that cells were being constructed with hanging points. We held a number of inquests where we listed some of the recent deaths by hanging, with obvious hanging points. Unfortunately, from our perspective, the media have very little interest in deaths in custody. They are not particularly concerned about deaths of prisoners. Much of our ability to effect change is driven through the media, because effectively we do not have any power to direct anyone to do anything. The media embarrass people into complying with our recommendations, and they are not doing a great deal of embarrassing in respect of deaths in custody.

Turning to our court itself, we have experienced massive difficulties, since I was appointed in 1996, in obtaining adequate resourcing. I should say that the present Attorney-General, Christian Porter, is the first Attorney who seems to be interested in the Coroner’s Court. He seems to be very supportive and on our side.

In respect of the bureaucracy in courts, we have received absolutely no support at any time. We have, for example, two counsellors who provide a 365-days-a-year service. When one of them was ill, we only had one grief counsellor providing a service for the entirety of Western Australia. I made a number of submissions to have some sort of increase in resources in that respect and it could not have had less impact.

In respect of IT, one of the concerns that I had was that we wanted to identify clusters of suicide deaths to identify regions where there were more suicides than one would expect. When I raised those matters within courts, it could not have possibly had less support. The priority would be absolutely zero, I would suggest. In a way, that is to an extent understandable because, within the courts context, they are concerned with listings and numbers of matters going to court and finalisations; matters such as whether or not resources are being allocated to identifying suicides are really outside their normal performance indicators or whatever the current bureaucratic concerns are.

The Law Reform Commission of Western Australia is currently conducting a review of the Coroner’s Court, so any recommendations that you might care to make in respect of our resourcing and in respect of these matters would be timely.

Obviously we have access to a wealth of information. That information is provided to a number of organisations. It is provided to the NCIS and the Ministerial Council for Suicide Prevention. Deborah Robertson comes to our office regularly and reviews the files. The Telethon Institute for Child Health Research receives information. Other legitimate researchers involved in suicide research also are provided with access to information. You have heard already, I think, about our interaction with ARBOR and other such organisations in respect of support for people.

In respect of the causes of suicide and so on, I do not think there is a silver bullet which will provide an answer to all cases or reduce suicide rates. Obviously low self-esteem, sexual abuse, hopelessness and depression are factors. I can make a few general observations from my own perspective, thinking about these deaths over a number of years. I am a great believer in positive health measures. I am a great believer in positive action. In the case that we did into the large number of deaths in the Kimberley, Professor Fiona Stanley spoke of how important she found it for young Aboriginal people to be playing sport, playing football. The involvement in activity like that improved self-esteem in young people, which made a significant difference.

I believe it is important to have a diversity of interests so that people’s whole life is not focused on, for example, a relationship. If you are going to split up with your girlfriend, it is perhaps not quite so bad as it could be if you are playing in the grand final of the football that weekend. I am a great believer in social interaction, not just computer interaction. I believe in stress relief and escape from mobiles and BlackBerrys.

I believe that increased pride is something that we need to foster in our community. I can remember people speaking years ago of being proud but poor. I do not think that exists nowadays. I think people who do the right thing should be proud of what they do. There is growing materialism in our community. That is very harmful, particularly the belief that people who have not got material possessions are somehow a failure in life. I can tell you that I have never seen a case of suicide where a person has killed himself or herself because there was not a second bathroom or three toilets in the house. But I have seen a lot of cases where young people have killed themselves because they thought their parents did not care because their parents were never there.

The sexual abuse of children is a huge factor. It is difficult to pick up just how extensive it is because it is not something that necessarily comes out in the investigations. Sometimes a suicide note will reveal that there has been sexual abuse. Sometimes someone will say that the deceased person spoke abut sexual abuse. As far as I can see, we are just getting the tip of the iceberg as far as that is concerned.

Family dysfunction is obviously a big factor with the increasing split-ups of families. Again that is perhaps something that does not come across quite so clearly in the files as it does in our office. I certainly get feedback from staff in a lot of cases that ‘this family is a very dysfunctional family when we interact with them’ even though it may not appear so from the evidence.

Mental health is of course a major issue. The feedback that we regularly have is that families would like to be more empowered to know more about what is happening with their loved one. Take, for example, if there has been a past act of attempted suicide. We have had cases where the family did not even know that that had happened and felt that they had not been placed in a position where they could adequately monitor their own loved one. Families are sometimes seen as a problem. The reality is that often they are the carers who have to look after the person when that person leaves the psychiatrist or psychologist. Confidentiality is an issue that needs to be addressed but should not be an excuse for not keeping families in some way empowered to know what to look for, even when families are part of the problem—and that is something that needs to be addressed as well by the mental health professionals.

Substance abuse is an obvious contributing factor and we see more involvement in particular by cannabis and of course by amphetamines, cocaine and all the drugs that are a problem. Cannabis, with its tendency to lead to schizophreniform disorder, schizophrenia and so on is having an unwelcome and increased impact. A number of Aboriginal people have spoken to me about that as well.

I make the observation that, while a number of the deaths seem to be totally unexplained by the evidence, some of those deaths may be sexual abuse cases and some of them may be cases where there are parental expectations and where family pressures have been placed on people. I can think of a couple of cases of doctors who have taken their own lives. They were doing extra training and they were not doing as well as they expected and they just could not accept that their family’s expectations would not be met.

In respect of a couple of matters I noticed you were discussing with the last witness, I refer to suicide and information about suicide, particularly information in the media about suicide. There is definitely a copycat problem but I believe that the fact of suicide and the problems associated with suicide can be spoken about openly and should be spoken about openly.

The copycat problem tends to occur more when people have a direct knowledge. You quite often see families where one family member suicides and another family member suicides. Also, in Aboriginal communities where people have come across a person actually hanging. They know the person, it is right in the forefront of their minds that suicide is an option and they take it themselves. But I think, generally, non-inflammatory, non-ghoulish coverage information about suicide should be out there. I was interested to hear the last speaker also speak about Fitzroy Crossing, because that is one of the places we are particularly concerned about. It seems that the suicide rates are down there as well. More children are going to school. There is a huge reduction in the number of people turning up at the emergency department at the hospital and reported offences to the police are way down. So that is an example of a success story. That is all I have to say initially.

Senator ADAMS —Thank you. It was very interesting. Of your numbers, what percentage of your cases would have a mental health history? How many would be just out of the blue, completely and utterly for no reason whatsoever, no note left? Is there a percentage—for example, 75 per cent would have a background of mental health problems?

Mr Hope —It possibly depends a little on what you mean by ‘background of mental health problems’.

Senator ADAMS —Just the fact that that person had actually presented to either a GP or somebody. I come from a small rural community and just knowing what a suicide in the community does—it devastates the whole place. If the family know that that person had problems and they probably went to Bunbury or to Albany but did not go to the mental health team when they visited because everybody would know and then, out of the blue, completely and utterly—it is devastating.

Mr Hope —There are probably relatively few that are totally out of the blue but there are a considerable number of people who have had some form of treatment for depression or who have seen their GP or whatever. There is a whole range within that category and there are a number of people who obviously have had problems who have not sought professional treatment. But I would suggest the number is fairly small where there is something completely unexpected and there is no forewarning whatsoever. In most cases, people with histories of problems and distress, anxiety and so on may not have been treated. I could possibly give you the statistics on the numbers who have actually had professional help.

Senator ADAMS —Can we get an idea of the number of people who had sought help and the others—

Mr Hope —A significant proportion would have had some sort of mental health treatment. I could not give you an exact figure off the top of my head, though. If you are counting the people who have also seen their GP, who have had some level of anxiety or depression, it would be a significant proportion—probably half or so. For example, take the Aboriginal death cases, a lot of those people would not have gone to see a doctor about it, but it would not take too much exploring of the background circumstances to see that the person was obviously depressed and perhaps suffering from clinical depression.

Senator ADAMS —Something else that had happened.

Senator MOORE —What percentage leave notes?

Mr Hope —Not many.

Senator MOORE —I would not have thought so. The number would be quite small.

Senator ADAMS —As far as the families are concerned, when there is a suicide do you have someone who talks to the family and, more or less, investigates the evidence, finds out what the person was like before? Or do the police do that? How does that work?

Mr Hope —The police investigate the circumstances of the death, so they should be speaking to the family members and finding out the background. We provide the family with a grief pack and our grief counsellors write a letter inviting them to contact them. So quite often we do get feedback from the family through the grief counsellors and then through the family generally contacting our office.

The investigative role is with the police. They are expected to find out the circumstances surrounding the death and obviously, if there is a motive for a person to take their own life or there are mental health issues, that is something the police should be identifying. We specifically ask them to find out about the mental health. That is something we actually ask the police to find out about.

Senator ADAMS —I guess the other thing in the country is where there is a single-vehicle accident and a loan tree on a very straight stretch of road. Those are the issues to which, once again, in country communities there is stigma attached—did they or didn’t they? Were they getting through a fence with a loaded gun? With all those sorts of things for me it is hard when you come from a small community where everyone knows everyone and it is almost cruel the way the families have to suffer. And then there is not really much support for them because to have a psychologist or a psychiatrist available anywhere once again there is a six- or 12-months wait and that might end up with somebody else having real problems themselves. It is just so hard.

Mr Hope —I could not agree with you more. In fact, one of the things which has disappointed me most about our inability—and this is one of the reasons I mentioned the resourcing issue—is that we have not been able to provide any face-to-face counselling in the country because of the fact that we have had only two grief counsellors. We actually have temporary funding for three at the moment—I am hoping it will be made recurrent. With three counsellors, the very first task I have asked our senior counsellor to do is to go out into country regions to find out what the resources are so that even if our counsellor does not go out we are aware of, for example, victim support service people or a nurse at the local hospital, someone who can be called on to provide some face-to-face interaction at that early stage, even if the subsequent ongoing counselling is passed on to somebody else.

Senator ADAMS —I think it is terribly important. With community members, you can see someone walking up one side of the street and people physically dodging over to the other side of the street so that they do not have to confront that person because they are embarrassed and do not know how to do it. It is really hard. In the city, I guess you can get away with it a bit more because people do not know one another in quite the same way. It is very sad.

Mr Hope —In some of the country areas, the description has been given to me that whole communities are almost paralysed with grief, especially when there has been more than one suicide. If there have been two or three suicides—

Senator ADAMS —Narrogin has been an area where Indigenous people took their lives but as far as the whole community was concerned, they were all in grief—not just the Indigenous people but everyone was saying, ‘What’s gone wrong; why did it happen?’ There are all the issues that go with it. It is a community which appeared stable, apart from the families feuding and things like that, but that has been going on for generations so it is not new. That community is struggling to get back on its feet.

Mr Hope —We are going to have an inquest about those suicides. I do not know whether it is going to achieve some of the things that we achieved, hopefully, with the Kimberley one. Sometimes a benefit of the inquest is to show that there are positives as well as negatives and hopefully that may happen with that community. A really classic example was just out of Fitzroy Crossing in Mindi Rardi, a small Aboriginal community. In just about every second house there someone had either suicided or died some sort of tragic death. You can imagine what the community at Mindi Rardi was like—they were absolutely unable to go forward.

CHAIR —When we were in the Northern Territory we had evidence there that in Aboriginal communities on average a person will have had 12 traumas in their life and trauma was counted as a death of someone close to them, in their family or their community. If everybody in the community is suffering that sort of trauma, moving forward is really difficult.

Mr Hope —It is a very full-on interaction that they have, too, compared with what happens in the city, where everything is a bit sanitised. In an Aboriginal community, for example if young children have found the deceased hanging, and then the body is still there for a while and everyone is standing around looking at the body for a period, everybody in that whole community has seen the body and has seen the police come up, it is all very much in front of them.

CHAIR —I would like to go to the issue of resources, following up the comment that you made. This also brings to mind Narrogin. Over the last couple of days we have been talking a bit about Narrogin and the fact that Oxfam is still providing funding for a part-time psychologist to be able to come out to the community. But they still do not have a full-time male or female social worker, and their Indigenous support worker has just pulled the pin because he has been working flat out. That is what it is like living in community when you are the sole support person. He has just pulled the pin because he is having trouble coping as well. So here we have a community where we know very well that there are problems, but we still do not seem to be able to get resources for that community—let alone any of the other communities where there is potentially less need on the surface, and people may know about it but it is not so obvious.

Mr Hope —It is pretty hard to get people out into the country, for a start—not just social workers and psychiatrists. We deal with hospital deaths and so on. In some of the country regions they are bringing in overseas doctors who are working in the emergency department when they have not done anything in emergency for 30 years. All sorts of problems are happening. Basically, I have told my secretary that if I am sick and we are in the country to get me on a plane and fly me to Perth and pretend I am all right! I think it is a common problem in the country. Obviously, when mental health resources are strained anyway, in some of the country regions—I would expect throughout the whole wheat belt, for example—they are virtually non-existent.

CHAIR —You made comments around resources for counsellors but also about clusters. Could you go into that in a bit more detail?

Mr Hope —Our concern was that we did not have any proper computerised file management system in our office at all, or any computerised system that would help us to identify anything about what was happening with our matters; whereas, every other section of courts in WA has had some sort of IT software system put in to help them manage their caseloads and so on. Every time we were about to get something we would be bumped off the list. One of the types of things I wanted to monitor were clusters of suicides and things like that. So at the moment we are very much reactive. We get feedback from local people who tell us there have been a lot of deaths in a particular area. I would like to be a bit more proactive and be able to act more quickly and to actually monitor things. When I raise those sorts of issues it is just treated as highly unimportant by the bureaucracy—for example, that was part of a business case and they thought it was so unimportant they did not even present it to the minister.

CHAIR —So you still do not have resources for doing that?

Mr Hope —Hopefully we will have some resources. I have not actually seen this happen yet, but we are getting an add-on to the NCIS system which I hope will enable us to target these particular problem areas. I believe that is underway.

CHAIR —A number of other states have raised issues around being able to properly identify the number of Aboriginal people who have committed suicide because the identification process, in terms of the forms, does not always identify someone as Aboriginal. Is that the case in WA or are you fairly confident you have the figures pretty well okay?

Mr Hope —Aboriginality is a question our police ask about. How accurate is it? It is a pretty tricky area, but it is certainly something that we ask about. And it is being asked because we get some answer about whether or not someone is Aboriginal.

CHAIR —Okay. Thanks. We met with the ARBOR mob yesterday. They were talking about how your grief counsellors contact them in the even of a suicide and the notification could take anything up to two weeks because of various delays. Our Australian system is a legal system rather than a medical system. ARBOR model a lot of the work that they do on the American system. Because of the workload that your office has, they say that sometimes there is up to a two-week delay. Have you discussed that with them? Is there an issue there? I suppose I have a concern that, if they are then contacting the family and relatives of the person who has suicided, two weeks can be a long delay between when the suicide occurs and when the family is offered some support from their organisation. I am wondering if there is an issue there. If there is, is there a way that that time delay can be reduced?

Mr Hope —Our approach is to leave it to the families whether they want ARBOR to be involved. So we raise the issue with them. Then they come back to us. If they say that they want ARBOR to be involved, we notify ARBOR and say, ‘The family wants you to be involved and these are their contacts and this is the person you should contact.’ If the family says that they do not want ARBOR to be involved, we advise ARBOR that they have said that. But I do not know exactly what the delay is. But it is our view that we do not push things on families, because we are intrusive enough as it is. We leave it to the family to make that choice.

CHAIR —Okay. It was not clear from them yesterday that you go through a process of notifying the family about ARBOR before you tell them.

Mr Hope —Yes. We act as a sort of intermediary. Sometimes, people do not want to make a decision about anything straightaway. It might take them a while to decide whether they want to speak to anybody or not. We encourage them to use ARBOR, but it is not compulsory.

CHAIR —Okay. Thank you.

Senator MOORE —You talked about your resources issues. When the coroners from around the country get together, and I know that that happens at different times, is that an issue that is shared by all of you or are there some states better off? Or is it the ongoing resourcing and the interaction between the governments and you? Is that something that is a national issue?

Mr Hope —It varies from state to state. I am fairly optimistic about our current Attorney-General, as I said. The Law Reform Commission is doing a review as well. If they recommend that we take on more responsibility, I am reasonably confident that with the current Attorney-General that would be something that would be pushed and encouraged, which is good. For a long time, we have been the forgotten people, because in 15 years we have never had an increase in FTEs at all. We are the only part courts who have had no increase whatsoever. I have only one counsellor assisting who is a recurrent staff member. We had temporary funding for one other person. Now we have temporary funding for two. We are really at the bottom of the heap. State by state it is completely different. All the systems run differently and are different. In Queensland, thanks to Dr Patel, who has been very helpful for them, they have considerably more resources. They have a lot more coroners, a lot more counsel assisting and a lot more resources than we have. Victoria recently had a review. It seems that something bad has to happen. Our mistake has been not letting something really bad happen. In Victoria, there was a problem about wrong bodies being buried and then bodies having to be exhumed and things like that.

Senator MOORE —That would cause a bit of a stir.

Mr Hope —That was a bit of a stir. Then there was a big review, another Law Reform Commission review, and subsequent to that some more resources have been pushed into Victoria. So they have been picked up a bit. South Australia, I think, is reasonably content at the moment. They have a State Coroner and a Deputy State Coroner full time, and they have got a couple of counsels assisting. For their amount of workload I think that is reasonable. New South Wales, I think, is pretty much a basket case—they are really badly resourced.

Senator MOORE —They are a basket case, full stop.

CHAIR —I wasn’t going there.

Senator MOORE —I am happy to say it. It does not worry me. The other thing concerns the different ways that statistics are kept. I know you share. The way you presented your view on statistics is very much the way I feel about them, but nonetheless it does seem to me odd that there is not some form of national consistency in the way that statistics are retained in these areas. At the meetings that you have do people share best practice and suggest differences—allowing for individual state pride of course?

Mr Hope —It is something that has been on the agenda from time to time. Unfortunately, progress has been relatively limited. But it is something that we all agree would be a good thing, but we have not really achieved much. It is partly to do with the actual complexities of our own evidence gathering procedures and the different sorts of structures that we have. Even the funding to each of the Coroners Courts is quite different. Some of the counsels assisting come from the DPP and some of them are police and we have got a couple of people in our office. It is all a bit of a mishmash in respect of the structures of the offices and so on. But there is a general consensus that it is a good idea.

I think that the move is towards more findings of intent, because that was something that the Suicide Council raised with us. In a number of jurisdictions there were no findings about intent and it was not possible to determine whether or not a death was a suicide anyway even if you got hold of the file and read through it. I think that has probably been picked up on and improved. I mentioned it to Michael Barnes in Queensland. He has been trying to get much more consistency in his state. So generally we are trying to work towards it. I do not know whether South Australia is improving in that regard.

Senator MOORE —We heard evidence in Queensland, and I knew about the issue in Queensland with the different regional centres having a different focus. But Barnes has been really pulling it together and it has been the focus of the last Attorney-General. I am not quite sure about this one but the last one had this as one of his key aims. He was a regional solicitor so I think he brought that to his process.

But what we did hear about in Queensland was the focus that came out through a range of interests about clarification of stats around children. When findings came to a coroner about child suicide Queensland has actually introduced a methodology whereby they keep stats for kids—and I have forgotten the age. Up until then everyone under a certain age was kind of lumped in together as a possible suicide, but now they have got clearer statistics—

Senator ADAMS —Ten to 14.

Senator MOORE —Ten to 14 was the focus, because they had actually had some cases. It is always stimulated by an event. The way they presented the evidence is peculiar to Queensland at this time and I was wondering whether that particular focus had been considered at your national meetings.

Mr Hope —No, that particular age group has not been the focus. It could be, but I do not really think that we have a huge number of deaths in that category in WA because we are so centralised. The Deputy State Coroner and I have basically decided, so there is consistency because there are only the two of us.

Senator MOORE —It is a good position. One of the things the committee has struggled with over many years has been the issue of privacy, and you mentioned it in your opening statement. We have had evidence from the whole range of views about confidentiality and privacy and the right of families and carers to have more information. In your role where you would be caught up in it a bit, I would imagine, in this terms of seeing the people’s views at the end, have you sensed any movement within that debate? It almost seems as though people know the debate but it is too hard.

Mr Hope —It is certainly a big issue. Our experience recently has been that there seems to be a move towards a consensus that you can address confidentiality issues. Especially in an acute suicidality context, families do not necessarily need to know the nitty-gritty of an issue, but they can certainly be alerted to some of the things to look for and some of the concerns. That is not a breach of confidentiality. If someone is at risk of harm and the matter comes up during a discussion between the practitioner and the patient—the possible suicidal person—there really should be an onus on the practitioner to resolve that with the patient and say, ‘I’m worried about this issue; I need to tell your parents that this is a problem,’ and then have the patient accept that that would be reasonable.

Senator MOORE —If you can get consent you are fine.

Mr Hope —You cannot pretend it did not happen and keep the parents in the dark without doing anything. I think there is a bit of an onus to raise an issue if it is something that is directly a confidential point and it is a life-threatening issue.

Generally, in respect of empowering people, I think there is an onus on practitioners to give carers some information—enough to empower them to know things to look for. An example is the sort of thing to look for to see when the patient is not complying with their medication—the way that the person is likely to behave if they are not taking their medication—so that the parents can pick it up.

CHAIR —I want to go back to what you record. We had the Ethnic Communities Council here earlier and we have looked at the new strategy, which highlights the number of suicides in the CALD community. The ECC were saying that it is quite difficult to get stats because ethnicity is not necessarily recorded. Is that an issue that has been brought up with you? When we have asked other people during the day about this it was clear that they did not have a good handle on this, and the stats that are quoted in the strategy are actually overseas stats. Has anyone discussed with you how they can get a better handle on ethnicity and issues around the CALD community? There seem to be some very significant issues there. Quite often you only start getting a focus of resources when you can start proving that it is a big issue.

Mr Hope —It is certainly something that has been discussed amongst the coroners, particularly when issues were raised about Indian related deaths in the context of assaults on Indian people in Victoria and that sort of thing. A question was asked about how many Indian people may have taken their own lives or may have been the subject of homicides and things like that. The fact is that we do not keep those statistics. It is something that we could ask police to ask. One of the big questions for us is what we need to ask police to ask. That is not something you can just change every five minutes because you have to give them a form and it has to be sent to every police station around WA—and everyone is going to lose it!

I have not seen a lot of evidence to suggest that ethnicity is a huge factor, to be perfectly honest. I see the problem as running through all cultures and races—all people. We take aboriginality but otherwise we have not particularly focused on a group, and I cannot remember people writing to me and saying that people in a particular category are suiciding more often or that there is a big problem there. I have not really seen the evidence to justify calling on the police to gather that information. It would be a bit fiddly, because I do not know how you decide whether a person is of, say, Indian extraction. How far back do you go? Who are you categorising as being an Indian person? I know there have been a number of assaults on people who have a particular appearance but they may have actually been living in Australia for two generations or something like that.

CHAIR —Yes. The points that were being raised with us are the issues around people who have been in detention—people coming as refugees. They are fitting into a new life. If they are young people and they are going into schools, they are often being put into grades where they do not have the necessary numeracy and literacy skills to cope. They have had trauma where they have come from, so they have to deal with those issues. Their parents do not necessarily pick it up because they are dealing with their own trauma. That was the background to the discussion we were having. If I understand what you are saying correctly, you have not noticed a significant proportion of people from the CALD community completing suicide.

Mr Hope —No, I certainly have not. I am thinking of all the files I have read but I cannot even think of a lot of cases where that has happened.

CHAIR —The other issue that the Indigenous team from the Drug Research Institute raised with us is the lack of research on alcohol and drug related issues with regard to completed suicides and what role drugs, in particular, have played in suicides. A high degree of substance could be in someone’s system but there is still a lack of research in what role that has played in suicide. You mentioned, particularly in the Kimberley suicides, that there were high levels of alcohol present.

Mr Hope —Very high, yes.

CHAIR —Are you aware of any research or been asked to be involved in any research into that issue?

Mr Hope —I cannot recall a lot of research. It seems fairly self-evident to me that the statistics reveal that there is a strong correlation between alcohol and suicidality and the problems associated with alcohol and suicide as well. Foetal alcohol syndrome and so on is manifestly bad. I do not really know whether there is any point in researching it. It is obviously a bad thing. We have picked up on cannabis, because we have had a number of deaths of people with mental health problems, and quite often there has been clear evidence of cannabis being a precipitator for mental health problems and drug induced psychosis and so on. There has been some pretty clear evidence in those sorts of cases. I think the evidence is pretty clear.

Senator ADAMS —I have a general question as far as your role as a coroner is concerned. With regard to sudden death—not necessarily suicide—I have heard lots of complaints about the time it takes from when the person passed away to the time when an interim death certificate is issued and then when a final death certificate is issued. How are you going in that respect?

Mr Hope —Those are exactly the sorts of issues I am talking about.

Senator ADAMS —I know; that was why I wondered.

Mr Hope —I mentioned that the present government did agree to give us some extra money, although it is all contingent on the Law Reform Commission’s determinations. We were given that money in August last year. By the time we had actually employed anybody and gone through all the HR things, it was pretty much December. We have now got a person, a clerk, who is working full-time to help our clerks to finalise our files so they can get through to us. And just yesterday we started a person who is working part-time as a coroner, using this funding that we have got, and he is just resolving files for us. So we are attempting to address that backlog as much as we can.

There is a big problem with the police as well. Our coronial police have got about 300 files that they have not been able to finalise, and they are really struggling. They just gave 70 to the major crime squad, who are probably not doing a huge amount. So we have our backlog, and they have another big backlog that is sort of sitting there. We have just recently got some money, so actually we have a few people beavering away non-stop to get these files processed. But that was the first time we had had any injection of funds in 14 years.

Senator ADAMS —That is good to get on the record anyway.

Mr Hope —Yes. Assuming that we get a continuation of the funding into next year, because the Law Reform Commission’s report will not come out until late next year, and depending on how much additional funding they give us, if there is enough to keep that person going then I would like to see that person who is helping finalise our files—that is the only thing he is doing at the moment—just continue on, because we are not going to get the backlog into a reasonable condition by 30 June. Sometime next year we would catch up reasonably with the backlog if we have continued funding.

Senator ADAMS —So are you reporting to the Attorney General? Do you report back there via an annual report?

Mr Hope —Yes. We have an annual report, and I have been keeping the Attorney reasonably appraised. As I said, the Attorney at the moment is quite supportive. But, as I said before, we have not really had much support from our department; they have never been supportive of any of our requests for funding for our budget or whatever.

Senator ADAMS —Nice! I mean, death is hard in any area but even harder, I think, with something like this, when you are waiting and waiting and waiting. And then of course probate cannot take place until 18 months later. I have personally gone through the whole system very recently and, doing what I am doing, it has been pretty jolly hard to get it finalised.

Mr Hope —It absolutely amazes me that we do not get more complaints. It amazes me that more people do not complain.

Senator ADAMS —Yes. I have had a few through the office but, probably because of my personal situation, I have been able to say, ‘They are doing their best, but …’ Just for the record, I was very, very happy with the support I got from your office.

Mr Hope —That is good. We have had a very small core of staff and just about everybody is owed massive amounts of leave because people have not been taking leave because they wanted to get things done. We have just had a terrific commitment from everybody in our office. If I ask someone to stay back and work they will do it, and they do not care about whether they get paid or not; that is just the sort of ethos of the office. People really care. When the Attorney’s advice came through in August that they were going to give some additional funding to help us deal with these things, there was a massive cheer in our office. That is just how committed our staff are and how pleased they were that we could actually start to give people a better service, because it hurts us as well. We hate holding people up. It is hurtful to us, and our staff are very distressed by it. They want people to get information in a timely fashion. They really care.

CHAIR —Just as a general reflection, it is often that way with essential services, and NGOs are the same. They keep running. Government relies on them very heavily—they rely on people’s goodwill and commitment to service. But, anyway, that is a personal reflection.

Mr Hope —That is right. If things go badly wrong, that seems to be when you get the funding. I guess because we have been working extra hours and we have been coming back and doing things we have reduced the number of complaints, so I do not know whether that was a good thing! And we have done things like making sure that matters are processed so that funerals can go ahead. Everybody just treats that as the number one priority, and if we have to do something we just do it.

Senator ADAMS —There is nothing worse than communication sometimes with the general public. They might go ahead and organise a funeral service and then, unfortunately, things are held up and they just do not really understand. Nobody expects these things to happen. But then they are at a loss as to how to deal with the situation and then think, ‘Well, there’s a spare slot there; we can do it on such and such a day and everyone will be here,’ and then all of a sudden the body is not available to be sent to wherever it has to go.

Mr Hope —Essentially, we never hold up funerals by our own mistakes. Where funerals have been held up it is sometimes funeral directors not having understood that the process might take a bit longer. People objecting to autopsies can cause delays. Funeral directors who understand that warn people so they do not organise a funeral until those matters are resolved. Our office basically reacts with that as our No. 1 priority and trying to get people answers is our No. 2 priority. That is why some of the other things have taken longer and longer.

CHAIR —I have two questions that have come out of evidence we have had in other states. Do you hold inquests for suspected suicide sometimes? If you suspect a suicide, would you hold an inquest?

Mr Hope —Not just for that reason. We only hold inquests where we see that there is a positive purpose to it. If there was some belief that somebody was withholding information and the only way we could get it was by an inquest, we would have an inquest. It is usually much quicker and more effective in helping us resolve the matter if we just ask the police to find out what happened about this or that and chase up further investigations as a result of that questioning.

CHAIR —The Public Interest Advocacy Centre in New South Wales suggested that coroners make recommendations after inquests for suspected suicides. You can make recommendations anyway in WA, can’t you? You do anyway.

Mr Hope —Yes, but usually after an inquest where we give everybody an opportunity to be heard as to the types of things we might make recommendations about.

CHAIR —But you do not need to be given any additional powers to do that because you already have those powers, don’t you? It is up to you to decide in the public interest—

Mr Hope —That is right. We have the powers to make comments and recommendations.

CHAIR —Not all coroners apparently around the country have those powers. Is that right?

Mr Hope —I do not know whether they are thinking about in the cases that are not inquested. It may be in the cases that they do not inquest they do not make recommendations, but we would not normally make them anyway. If there was a death prevention issue that we wanted to get out there, we would hold an inquest, otherwise no-one is going to know about it.

CHAIR —Another issue that has been raised is the role of the police in assisting people who they think are at risk of suicide. Have you had any involvement in that area? Do you have any comments to make on that? We have to look at the effectiveness of agencies in terms of dealing with people at risk of attempting suicide.

Mr Hope —The WA Police are a huge amorphous mass, are not particularly disciplined and are completely different from area to area and individual to individual. A lot depends on the particular police officer and the particular location. One very good innovation by WA Police to their great credit is the multipurpose, multifunctioning units that have been constructive in the country. That places a child protection worker and a police officer in the same room. I think that is a very positive step. It helps to have them both know about the issues affecting each other.

CHAIR —That is happening in the bush though, but it is not necessarily happening in the city. We have been to the Balgo centre several times. I agree with you. I understand that one in Warburton is working well as well. So what you are saying is that it is a bit ad hoc around the state?

Mr Hope —Very much so, yes. We have had police called to a scene where somebody is apparently suicidal and sometimes they have acted positively, well and efficiently and other times they have not. Sometimes they have mucked around when they should have stepped in to save someone’s life. It depends very much on the particular officers, the amount of training they have had and who they are.

CHAIR —Around Australia we have heard about the lack of consistency in training in addressing mental health issues for front-line services—ambulance officers, emergency service people, emergency departments and the police. There seems to be even within states and certainly between services an inconsistent approach to training.

Mr Hope —I think I made a recommendation about that in one of the inquests. Certainly it is a very important topic. Police definitely need to train their people more with respect to mental health issues. I have had some feedback that they are improving their training, but I do not know the extent to which that is true. It is very important for them, apart from the suicide issues, just for their protection. The two cases where police officers have been shot and were almost killed were where there were mental health problems. Police were inadequately skilled really to respond and put their own lives at risk.

Senator ADAMS —Do you in your role get an opportunity to speak to the classes before they graduate about what the role of the coroner is and how important it is what they do and don’t do?

Mr Hope —I do not personally, because there is only one of me. Our office has tried to become more involved. I have gone along to graduation groups. We sometimes have had involvement and sent someone down to explain what the Coroner’s Court does. We are eager to increase education. That is a big issue. Training at the police academy in respect of coronial matters is pretty much nonexistent. We are very eager to have that upgraded and have more input into that.

Senator ADAMS —Can you put that in your annual report this year?

Mr Hope —We very possibly could.

Senator ADAMS —I think it is terribly important because people are getting busier and busier. Out in the rural and remote areas the pressure is on. If police really understand what you do, they could help families a lot more by being able to explain the process. Five minutes could really clarify everything and they would know what to expect.

CHAIR —That is an issue that has come up with particularly bereaved parents. They have not been told what has been going on at all. If the suicide happens at home, they are locked out of the home and have nowhere to go. It varies in different states, but sometimes they have not been told what is going on and have not been given any numbers to phone for support. Even if the police could give them a bit more support, it would be useful.

Mr Hope —It would be very helpful for us as well. We have two police officers attached to our office, although one of them might be going away. When they are there a lot of the time they interact with police, often in the country, who are investigating sudden deaths and do not know what to do. About 80 per cent of their work is trying to help them and tell them what they should be doing. It would be an awful lot easier if the academy taught them in the first place. Even so, I think it is great that they do interact with somebody who knows a bit about it so they are passing on reliable information.

Our brochure goes to every family. It is mandatory that the brochure be served before an autopsy, so every family will get a copy of our brochure. Our grief counsellors send a letter to all families of suspected suicides. At least people can contact our counselling service, which will tell them about factual issues as well.

CHAIR —Thank you very much for your time. We very much appreciate it.

Mr Hope —It has been my pleasure. It is extremely important to me, as you can imagine.

Committee adjourned at 3.35 pm