State Coroner

In Parliament, Motions

Adjourned debate on motion of Hon. C. Bonaros: 

That this council— 

1. Acknowledges the retirement of State Coroner Mark Johns in August 2019, after a long and distinguished legal career in private practice and the public sector; 

2. Recognises the exemplary service, commitment and dedication to the role of State Coroner that Mark Johns has demonstrated over a period of some 14 years; 

3. Expresses its appreciation for the investigations and reports that Mark Johns has completed into often deeply tragic, highly sensitive and disturbing matters, to establish the cause and circumstances of deaths that fall within the events covered by the Coroner’s Act; 

4. Applauds the efforts of Mark Johns to provide findings and make recommendations that have contributed to the transparency and accountability necessary to fully harness the preventative function of the Coroner’s Court; and 

5. Calls on the government to better resource the Courts Administration Authority for the specific purpose of properly funding the work of the Coroner’s Court so that the court can be modernised and staffed at levels appropriate to deal with the increasing and heavy workload carried by this court. 

(Continued from 5 June 2019.) 

The Hon. T.A. FRANKS (16:29): I rise to support this motion and the tabled amendment to the motion. I commend the Hon. Connie Bonaros for taking this moment in this council to reflect upon the work of the State Coroner, Mark Johns, in his retirement. He is, like many members of parliament, somebody who does see the worst of people’s lives. It is a difficult job, it is a job that he has done with aplomb, and I think with dignity and respect, particularly for the families and loved ones who lose somebody to bring them to that point where they are before the Coroner’s inquest. 

I wanted to reflect particularly on Jorge Costello-Riffo today, and sitting in that particular inquest with Pam Gurner-Hall, and pay tribute to Pam and her courage and her dignity for the absolutely senseless loss of Jorge on the worksite of the new Royal Adelaide Hospital, where he should have come home safely that day but did not. I do reflect as well that the Coroner’s recommendations, the most simple of recommendations that could have been done in fact right from the time of Jorge’s death, that a spotter be employed to ensure the safety of any work done for any worker on an elevated work platform in order to be secure and safe in that job, has still not been implemented and could be implemented quite simply through the government’s say-so. 

I certainly think that the work the Coroner has done has informed this parliament, and in many ways has been respected by this parliament but should be more formally taken on board as these inquests make their recommendations, and certainly with those few words I commend the motion. I thank the mover for bringing and drawing attention to the fine work of the Coroner. I wish the new Coroner well, and of course the Deputy Coroners, who do such very important work on behalf of our state, day to day, in the most tragic of circumstances. 

The Hon. S.G. WADE (Minister for Health and Wellbeing) (16:31): I rise on behalf of the government to speak to this motion. I acknowledge the many years of dedicated service provided by former State Coroner Mark Johns, who officially left the role at the end of last month. I first worked with Mr Johns professionally when I was an adviser to former minister Armitage. At that time Mr Johns was a lawyer in the Crown Solicitor’s Office and was advising on Aboriginal heritage issues. I have certainly enjoyed a long-standing relationship with Mr Johns professionally, and I respect him. 

The role of the Coroner is often to advocate on behalf of those whose voices have been silenced before their time, to identify where organisations or systems have let them down and to be an agent for change. Whether it involves the private or the public sector, Coroners seek to get to the heart of the matter without fear or favour, to look at what went wrong and at how things can be fixed to prevent further loss of life. 

For nearly a decade and a half, Mark Johns has performed this role with distinction in this state. He has probed instances too numerous to count, some of which have shocked our state. Mr Johns spoke up for people like Zahra Abrahimzadeh, Jorge Castillo-Riffo, Michael Russell, Chloe Valentine, and so many others. In examining their deaths, Mark Johns gave them a voice and, where possible, provided a degree of solace to those they have left behind. 

Where systems and processes fail members of our community, Coroner Mr Johns spoke out strongly and thoughtfully and sought to improve processes so that other untimely deaths could be avoided. I have also found Mr Johns to be a person of both integrity and legal skill, qualities that have underpinned his service as State Coroner. Mr Johns’ legacy includes the multitude of improvements that have been implemented across government, in agencies such as health, corrections and police, that have arisen from these tragic cases. 

In health he was an early critic of EPAS, the previous government’s electronic health records system. On that, and in so many other cases, Mr Johns was proved right, and I am delighted that he had the opportunity to contribute his views and insights to the independent review on EPAS. In his time as Coroner, Mark Johns was forensic in his examination of key witnesses, even-handed in his consideration of the facts and competing testimony, and more than willing to challenge those who appeared before him if he felt they were not being forthcoming. 

It is unfortunate that leadership within government agencies can be defensive in their interaction with the Coroner’s Court. From time to time, an attitude of us and them develops. As minister, I seek to overcome this defensiveness because it should not be a matter of us and them. We, the South Australian community, rely on the work of the Coroner to help us all do whatever we can to ensure we learn what we can from unexplained deaths to avoid deaths in the future. Mr Johns’ work has often provided a sense of closure to those who have lost a loved one by answering questions arising out of untimely deaths. While it is the higher profile cases that are often in the public’s attention, there is considerably more to the work of the Coroner’s office. 

Each year, the Coroner considers more than 2,000 deaths that are reported to his office, determining whether a formal inquest is warranted or the type of work that may be required to determine a cause of death. The government acknowledges the important role of the Coroner and Mr Johns’ work as Coroner. 

Although the government supports the motion in terms of recognising Mr Johns’ outstanding service as State Coroner, it does not support the motion in relation to funding. Whilst budget matters for the Coroner’s Court are ultimately a matter for the Courts Administration Authority to determine, I note that in the 2017-18 state budget, $2.9 million was provided over two years for additional resources, as requested by the Coroner, which also provided for an additional Deputy Coroner to clear a backlog of cases, including a number of complex matters. Furthermore, in the most recent budget, the Attorney-General announced the purchase of a new CT scanner for Forensic Science SA, which will significantly reduce post-mortem wait times. 

In the context of those comments, I move to amend the motion as follows: 

Leave out paragraph 5 and insert new paragraph as follows: 

5. Acknowledges the appointment of Judge David Whittle as State Coroner by the Attorney General and the ongoing work of Deputy Coroners in their important role. 

In South Australia the number of post-mortem reports waiting to be completed has been rising. Apparently it sits, I am advised, at over 1,000 cases. I understand that any request for additional funding for the Coroner’s Court through the Courts Administration Authority will continue to be considered as part of future budget processes by the Attorney-General. 

The role of the Coroner is not an easy one. It is a role that requires stamina, an ability to grasp incredibly complex and technical systems and have a sufficient understanding of those systems to be able to make recommendations aimed at ensuring that those who use and manage these systems not only learn the lessons arising out of an untimely death but are able to chart a way forward so that our services and systems are safer and stronger. In nearly 15 years, Mark Johns has delivered that level of incisive, intelligent thinking to the Coroner’s Court, and for that we thank him. 

The Hon. C. BONAROS (16:37): Can I start by thanking the Hon. Tammy Franks and the Minister for Health and Wellbeing for their contributions. As alluded to, Mr Johns has relentlessly pursued his brief, investigating over 2,000 deaths every year—on a shoestring budget, and I appreciate the comments of the minister in that regard and the fact that the government is not willing to support that particular clause in this motion. 

I am happy to accept that in relation to this motion, with every intention of pursuing it further through other means. I think this motion in particular was one of acknowledging the Coroner’s work, so I accept that that is the government’s position. He did so to get the truth of every matter and to bring to account those people or actions responsible when there, of course, has been a sudden or unexplained death. 

If I can just say this: I think we were very fortunate to have such a compassionate, dedicated and diligent Coroner in Mark Johns, again as acknowledged by my colleagues the Hon. Tammy Franks and the Minister for Health and Wellbeing. I thank him for his outstanding public service to the people of this state and wish him well in his retirement. 

I also acknowledge, of course, the appointment of Magistrate David Whittle as State Coroner and the equally important work of our Deputy Coroners and, to that end, indicate that I will be supporting the suggested amendment by the Minister for Health and Wellbeing and thank him for that inclusion into the motion. 

Amendment carried; motion as amended carried.