State Coroner

The Hon. C. BONAROS (16:16): I move:

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.

I rise to speak on my motion, acknowledging the imminent retirement of State Coroner Mr Mark Johns. Mr Johns has a long and distinguished legal career. A born and bred South Australian, he attended my alma mater, Adelaide University Law School, and was admitted to the bar in February 1980. He was appointed State Coroner in September 2005, after some 25 years of outstanding legal practice in the private and public sectors in a variety of roles, including as parliamentary counsel, senior positions in ASIC, the Crown Solicitor's Office and as CEO of the justice department.

In rising, I express our deep and sincere gratitude for the outstanding service that Mr Johns has provided to this state, diligently investigating and conducting inquests into approximately 2,000 deaths per year, on what can only be described as a shoestring budget. It is precisely for this reason—pertaining to the shoestring budget, of course, and through no fault of the Coroner himself—that he has the unenviable task of needing to prioritise cases he can or cannot investigate. At the same time, he has to balance the expectations of grieving families and the public, and what is achievable within the financial constraints of his court and, of course, the legal parameters within which he operates.

Deaths in custody, reportable deaths of persons under the guardianship of the state, unexplained disappearances, fires and accidents all come within the jurisdiction of the Coroner, who is tasked with ascertaining the underlying causes and circumstances of these events. Mr Johns has relentlessly pursued his brief to get to the truth of the matter and to bring accountability to the equation when there has been a sudden or unexplained death. His firm but fair approach has shone a light on all the errors, failures, acts and omissions that have contributed to or caused deaths in circumstances that might have otherwise gone unreported, undetected or even covered up.

The often thankless work of the Coroner has played a vital role in not only improving the transparency and accountability of agencies and private individuals but has had a major impact on law reform, policy development and procedural reforms in critically important areas such as child protection, mental health, industrial safety, medical practice, correctional services and policing. His findings and recommendations have directed the attention of the public, often via the media, to the best and worst of human behaviours, including instances of neglect, wilful and reckless abuse, betrayals of trust, failures of duty of care and sheer incompetence.

But for Mark Johns, our courageous Coroner, we would not know in minute detail the acts and omissions of the police that, had they been handled differently, might have prevented the tragic, fatal shooting of young Christopher Wilson—and can I just add, the absolutely tragic situation in relation to Mr Wilson's death which subsequently left his younger brother battling mental health illnesses and subsequently taking his own life as a result of not being able to cope without his brother and what they had lived through. Those deficiencies were comprehensively investigated to ensure that there would not be a recurrence of the events leading up to the death of Christopher Wilson. On a broader scale, this inquest also highlighted that the Police Complaints Act should not provide secrecy provisions that inhibit coronial investigations.

But for Mark Johns, we would not have known about the systematic failures of the child protection system that so tragically failed to protect the precious life of four-year-old Chloe Valentine. We would not now have enshrined in law some of the 20 comprehensive recommendations primarily addressed to the comprehensive failures of Families SA.

But for Mark Johns, we would not know of the systematic failures of SAPOL to protect women from domestic violence and that failed to prevent the death of Zahra Abrahimzadeh at the hands of her violent and abusive husband. The Coroner's recommendations to the premier at the time and media coverage of the facts uncovered by the Coroner played an important role in significant reforms being introduced and additional funding being directed to address and prevent endemic domestic violence in our community.

But for Mark Johns, we would not know how the health system so appallingly failed stroke victims Michael Russell and Leslie Graham with fatal consequences. Without this inquest it may have otherwise appeared that these unfortunate stroke victims were accorded the high standard of health care that we expect to be delivered in our public hospitals. We could never have imagined the dysfunctional behaviours and practices of highly trained specialists, doctors and hierarchical health systems that worked against these patients' possible survival from stroke.

But for Mark Johns, there would be a very high likelihood that another young unsuspecting apprentice like Daniel Madeley would be killed while working on an ancient, dangerous piece of machinery without even the most basic safety protections and precautions in place. We would not know of the failures of SafeWork SA in regard to equipment inspections or the failures of the company Diemould to provide a safe workplace for Danny and his workmates.

But for Mark Johns, we would not have any appreciation of the inevitability of the industrial worksite death of Jorge Castillo-Riffo from operating what we now know are deathtrap scissor lifts. We would not know about the failures and incompetence of SafeWork SA to properly investigate his death, and its abdication of its responsibilities to SAPOL. We would not know about SAPOL's subsequent botched investigation. Importantly, we would not be able to ensure the accountability of employers, regulators and the government to address the failures identified. Informed by the Coroner's recommendations, we can continue to press the government to act. Without government action, the 12 deaths and countless injuries attributable to scissor lifts in Australia will continue to rise.

But for Mark Johns, we would not know about how Colin Craig Sansbury was able to hang himself in the Elizabeth police cells using his disposable overalls, unobserved for 40 minutes despite having been identified as a serious suicide risk and having been seen and discharged by the Lyell McEwin Hospital. We would not know about the blatantly biased and self-serving police investigation into that matter. The inquest into Colin Sansbury's death was held in 2007, some 16 years after the royal commission into Aboriginal deaths in custody that had identified the glaring deficiencies that existed in the standard of care afforded to persons held by SAPOL and Corrections.

I hope to be a strong advocate against poker machine addiction, and I am intimately aware of the shocking circumstances of the suicide of young mum Katherine Natt. The Coroner found that her addiction to poker machines contributed to her death and, although Katherine's mum and I felt somewhat let down by the findings at the time because they did not include recommendations about the responsibility of gambling venues to their employees and patrons, the inquest has helped to inform my continued advocacy for gambling reform.

Of course, it would be remiss of me not to mention the tragic death of Jack Salvemini. Regrettably for Jack's family, the circumstances surrounding his death remain unsatisfactorily resolved. However, as I said in my maiden speech in this place, I have given my word to Jack's family—and I continue to give my word to Jack's family—that I will continue to advocate on their behalf, something that is becoming increasingly difficult with the passage of time.

I could go on with more and more coronial inquest findings, but I will spare us the trauma. I did a quick count and, over the past 13 years, I have been involved in and advocated for more cases that came before the Coroner than I wish I needed to. All of them touched me personally and, to this day, they are regularly in my thoughts, as are the families left behind. However, they also serve to drive me daily to ensure that justice can prevail and that errors of the past are brought under the spotlight.

Just over a week ago I had the unfortunate situation of meeting with the family of a young man who tragically took his own life after struggling with mental health issues, and committed to do exactly the same for them. Of course, these do not drive just me, they drive other members as well.

I am not sure whether the Coroner is truly aware of the life-changing impact his work has on many individuals who have appeared before his inquests, particularly family members. Andrea Madeley, whose son Danny I referred to earlier, chose to represent herself during her son's inquest, and her courage and determination in the face of her worst nightmare was nothing short of astounding. There were many days when I didn't think, when Andrea didn't think, she would get through it, when she could not bring herself to get back into court to continue with the questioning of witnesses in relation to her son's death.

However, what she helped uncover gave her unbelievable strength. If there could ever, ever be a silver lining it was that Coroner Johns and the inquest into Danny's death—his senseless and tragic death—drove her not only to advocate for other families but ultimately formed her future direction in completing a law degree as a mature age student. In a recent post, based on discussions I had with Andrea, she said:

Our State Coroner Mark Johns is resigning. I wonder if he realises just how much he impacted my decisions after the inquest into Danny's death.

I am today a law graduate about to embark on a career I am deeply passionate about, largely because of what I learned from his court.

I just wish more workplace fatalities would have been given the benefit of an inquest to flush out some of the underlying causes of these highly preventative tragedies.

Thank you sir, for allowing me to feel the difference between the law, the truth and justice.

Corner's inquest findings reports can, of course, be very sobering reading. I cannot begin to appreciate the evidence Mr Johns has heard and seen. I can only imagine how deeply troubling and harrowing participating in a Corner's inquest is for the family and loved ones of a person who has died in circumstances that have warranted an inquest or investigation.

Most families express their deep wish that no-one else ever has to endure the horror and grief that they have experienced through the death or injury of their loved one, workmate or colleague. These few cases to which I have referred today do not do any justice to the contribution that Mark Johns' frank and fearless inquest findings and recommendations have made to preventing or reducing the likelihood of further injuries and deaths. They also do not even begin to illustrate one of the most disturbing aspects of coronial investigations and inquests, and that is that in countless cases the recommendations of the Coroner remain outstanding, unaddressed and not responded to.

In regard to Aboriginal deaths in custody, a large number of coronial inquest findings and even a royal commission have not been sufficient for governments to see fit to implement all those recommendations. As a member of this parliament, I have some appreciation of how frustrating that realisation must be to our departing Coroner.

In closing, I will leave members with a quote that speaks volumes about the compassion and sensitivity the Coroner has demonstrated throughout his tenure and why he is held in the highest regard by the public and the profession. Mark Johns included this quote, attributed to Jeremy Sammut, as the introduction to the Chloe Valentine inquest findings. The quote is, sadly, still today, some five years after the Chloe Valentine inquest, a salient reminder that we must remain vigilant to the ever-present failures of the child protection system and the unrelenting need to demand transparency and accountability from those agencies entrusted with the care of our most vulnerable. I quote:

The wrongs hereby perpetrated are of biblical proportions; doubly wicked are those who protest otherwise but must know, in their hearts, minds and consciences, that what they say is false.

With those words, I conclude my remarks.

Debate adjourned on motion of Hon. T.J. Stephens.