Despite governance processes being in place, we found the Department frequently closed recommendations without full implementation. Actions taken to improve processes and practices did not always meet the intention of the Coroner’s recommendations, or at times only addressed them in part.

We recognise that the Department takes seriously its responsibility to prevent deaths in custody. It is hoped the findings if this report lead to changes that strengthen existing processes and help prevent future harm.


Page last updated: April 12, 2023
Directed Review into the Department of Justice’s performance in responding to recommendations arising from coronial inquiries into deaths in custody