Coroner's Act In the matter of Coroner's Findings and Recommendations into the death of Kunmanara Forbes pursuant to section 46B dated 2 December 2009
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investigation should be completed between 6 weeks and 6 months after the date of death. This is a realistic and appropriate expectation, but it is not being met in a substantial number of cases, and this is unsatisfactory. Delays in coronial investigations are not only distressing and frustrating for family members and other persons and organisations involved with the deceased, but they compromise the accuracy, reliability and effectiveness of the investigation itself. In this particular case there were a number of factual matters which I could not resolve due to the delays. A/Commissioner McAdie acknowledged that it is a police management responsibility to ensure that appropriate timelines and standards are adhered to. As I indicated to counsel for police at the outset of the inquest, I propose to make specific recommendations in respect of this issue and I do so below. ! Recommendations 54. For the reasons that appear above in these findings, I make the following recommendations pursuant to s35(2) of the Coroners Act. (i) I recommend that the Police Commissioner ensure that the Coronial Investigation Unit in Alice Springs is appropriately staffed and resourced in order that the members of that Unit are able to, and do investigative, oversight and liaison functions in relation to deaths reported to the Coroner in the Southern Command in a similar way to the operation of the Coronial Investigation Unit in Darwin. exercise (ii) I recommend that the Police Commissioner put specific strategies in place to ensure that reportable deaths are investigated by police officers in the Northern Territory in a timely way, with the expectation being that a coronial investigation file of satisfactory quality will be submitted to the Coroner within 6 months from the date of death. (iii) I recommend that the Director General for the Department of Health introduce an Adolescent Health Service within NT Department of Health. 21