A national system of accountability is needed to ensure findings by coroners are used to inform suicide prevention measures for Aboriginal and Torres Strait Islander people, according to new research from The University of Western Australia’s Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention.

Professor Pat Dudgeon, Director of the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention and the report’s lead author, said the findings made a clear case for investment in the coronial systems to respond to the needs of Indigenous people.

“It is simply unacceptable that Aboriginal and Torres Strait Islander families, who lose loved ones to suicide at more than double the rate of other Australians, have to go through a system that does not recognise their culture and that many find intimidating and alienating,” Professor Dudgeon said.

The report, Coronial Responses to Suicides of Aboriginal and Torres Strait Islander People, also calls for: identified liaison roles to support Indigenous families in the coroners’ court, staffed by Aboriginal and Torres Strait Islander people; ongoing cultural training for coroners and their staff, provided by Indigenous people; revision of information brochures and written communications by the coroners’ court to make them appropriate for Indigenous people; and law reform where required to ensure coroners consider Aboriginal and Torres Strait Islander cultural requirements, such as establishing a person’s next of kin.

Professor Dudgeon said a national system should be established to examine suicides of Aboriginal and Torres Strait Islander people, identifying patterns in the time leading up to the event and use that information to develop targeted prevention strategies.

“Such a system could be modelled on the Australian Domestic and Family Violence Death Review Network, which looks at all family violence deaths and makes recommendations for systemic change,” she said.

“The Australian Bureau of Statistics last week released data showing Indigenous suicides were at their highest rate ever in 2022 and have continued to rise for over a decade.

“It is time for all jurisdictions to acknowledge that Aboriginal and Torres Strait Islander suicide is a crisis and respond by investing in the solutions proposed in our report.”

The report is based on the perspectives of Aboriginal and Torres Strait Islander people who have been bereaved by suicide, interviews with coroners, community organisations and others with a personal or professional interest in Indigenous suicide. It included a workshop with Aboriginal and Torres Strait Islander family members who have lost loved ones to suicide, convened in collaboration with the Aboriginal and Torres Strait Islander Lived Experience Centre, part of the Black Dog Institute.