1. © Coroners Court of Victoria1 Safety culture as a factor for traumatic work-related deaths: a review of coroners’ recommendations Lyndal Bugeja and Ashne Lamb Coroners Court of Victoria

2. The Coroner

3. © Coroners Court of Victoria3 The Coroners Court of Victoria Australian coroners system adopted from England at the time of settlement First Victorian Act which referred to Coroners was the Coroners Statute 1865 Victoria has a centralised coronial system with 10 full time coroners Coroners must be legally trained with at least five years practicing experience Judge Sara Hinchey, State Coroner of Victoria

4. © Coroners Court of Victoria4 Legislative Mandate Established as a specialist inquisitorial Court by the Coroners Act 2008 (Vic) The Act states what coroners must investigate and how this investigation should be conducted – Reportable deaths – Reviewable deaths – Fire without death

5. © Coroners Court of Victoria5 Reportable Deaths Section 3 of the Coroners Act 2008 (Vic) defines a reportable death as: – body in OR death occurred in OR usual resident of Victoria AND – death was unexpected, appears unnatural, violent, or result (directly or indirectly) of an ACCIDENT or INJURY OR – during or following a medical procedure OR – identity is unknown OR – medical practitioner not signed a death certificate OR – death occurred in ‘care or custody’ or while under control or custody of the Secretary of the Dept of Justice or Victoria Police OR – death of a patient within the Mental Health Act 1986 (Vic) OR – death of a person subject to a non-custodial supervision order

6. © Coroners Court of Victoria6 Work-Related Deaths Occupational Health and Safety Act 2004 – Duty to Notifiable Incidents at a workplace where employees or self-employed persons work – Notifiable Incidents Death or serious injury – Investigation of Notifiable Incidents to determine breach of non delegable duties – Prosecution of Notifiable Incident WorkSafe may prosecute – Coronial investigation suspended

7. © Coroners Court of Victoria7 Coroners’ Investigation Initial Investigation Forensic Medical and Scientific Investigation Further Investigation Coroners’ Findings Coroners’ Recommendations A/Prof David Ranson, Victorian Institute of Forensic Medicine

8. © Coroners Court of Victoria8 Coroners’ Finding With inquest Without inquest Must include - identity of the person who has died (if known) - the cause of death - information needed to register the death May include - circumstances in which the death occurred - recommendations or comments

9. © Coroners Court of Victoria9 Coroners’ Recommendations Public health and safety Administration of justice Responses to coroners’ recommendations - public statutory authorities or entities - ministers are not required to respond - must respond within three calendar months - responses must include what action has or will be taken - must be published on the CCOV website

10. Coroners’ Recommendations on Traumatic Work-Related Deaths

11. © Coroners Court of Victoria11 Traumatic Work-Related Deaths Recommendations made under Coroners Act 2008 [enacted 1 November 2009] Presence of 9 elements of Safety Culture Level of intervention recommended Nature of strategy recommended Organisation directed recommendation Type of organisation directed recommendation

12. © Coroners Court of Victoria12 Definitions and Categories Safety Culture 1.Communicate company values 2.Demonstrate leadership 3.Clarify required and expected behaviour 4.Personalise safety outcomes 5.Develop positive safety attitudes 6.Engage and own safety responsibilities and accountabilities 7.Increase hazard/risk awareness and preventive behaviours 8.Improve understanding and effective implementation of safety management systems 9.Monitor, review and reflect on personal effectiveness

13. © Coroners Court of Victoria13 Definitions and Categories Level of intervention recommended – Legislation – Policy – Advocacy Nature of strategy recommended – Environmental / product design – Education / training – Behaviour change Type of organisation directed recommendation – Government or statutory authority – Non-government – Multiple

14. © Coroners Court of Victoria14 Results Period 1 November 2009 – 1 April 2016 Deaths occurred between 2001-2013 37 traumatic work-related deaths with recommendations 82 recommendations made 15 recommendations repeated 67 unique recommendations examined

15. © Coroners Court of Victoria15 Results

16. © Coroners Court of Victoria16 Results

17. © Coroners Court of Victoria17 Results Strategyn% Environment / product design change1217.9 Education / training3856.7 Behaviour change69.0 Other69.0 Not Stated57.5 Total67100.0 Level of Interventionn% Legislation23.0 Policy3856.7 Advocacy2638.8 Not Stated11.5 Total67100.0

18. © Coroners Court of Victoria18 Results Organisation specified in recommendations – 53, 79.1% Organisation directed recommendations – WorkSafe Victoria30 – Energy Safe Victoria9 – Farmsafe Australia6

19. © Coroners Court of Victoria19 Conclusions Coroners largely aligned to elements of safety culture Focus on: – advocating for policy development / refinement – educative and training material used to guide hazard identification and safe systems of work – will recommend design change and for legislative change – reliance on organisations with state-wide safety mandate to lead and communicate health and safety

20. © Coroners Court of Victoria20

21. © Coroners Court of Victoria21 Thank You