State Coroner given greater investigative powers due to SA-BEST amendments

22 March 2021

The State Coroner has been given stronger powers to ensure he is able to conduct full and thorough inquests under amendments introduced by SA-BEST. 

SA-BEST MLC and Attorney-General spokesperson, Connie Bonaros, made a number of crucial – and long overdue - amendments to the State Government’s Coroners (Inquests and Privilege) Amendment Bill 2020 when it was debated in Parliament last week. 

Among her key amendments – which were supported by both the government and the Labor Opposition – are to: 

  • compel a witness to answer a question or provide evidence even in circumstances when what they say may be incriminating; 
  • allow the Coroner to investigate events leading up to and after an event to be included in any inquiry; 
  • allow the Coroner to look at the quality of care, treatment and supervision of the deceased person prior to their death; 
  • put beyond doubt full legal representation for the family of a person to whom the Coroners proceedings relate to appear, to examine and cross-examine any witness testifying in the proceedings, and; 
  • ensure the government is held accountable after recommendations are made by the State Coroner by ensuring it updates Parliament with its progress in implementing the recommendations within six months. 

“These crucial amendments will be of great help to the hundreds of families whose deceased loved ones are the subject of a Coroner’s inquiry,” Connie said. 

“By their very nature, a Coroner’s inquest is a very traumatic, emotional experience – but the importance of the Coroner’s findings cannot be overstated enough – they serve to benefit the community,” she said. 

“The whole purpose of a Coroner’s inquest is to investigate how a death occurred – and to try to ensure another similar death doesn’t occur….to try and prevent the same mistakes from happening again. 

“It is the most important means of ensuring the accountability of employers, regulators and government agencies.” 

Connie sighted the tragic murder of Christopher Wilson as an example of where her amendments – and subsequent recommendations from the Coroner - may have prevented his death. 

Christopher, 23, was shot and murdered in cold blood by Hootan Biegzadeh on 28 February 2004. 

Two days earlier Christopher, his brother, Mark, and his friends reported an incident to police following an unprovoked altercation in which Biegzadeh fired a shot at the road which ricocheted and scraped Christopher’s leg. There was no motive for the attack other than Christopher and his friends had driven down the street where Biegzadeh lived. 

Almost a year earlier (March 2003), Beigzadeh was involved in an altercation at a fast food outlet in Adelaide where – while wielding a long-barrelled pump action firearm - confronted patrons shouting he was going to kill a person he had earlier had a dispute with. He was arrested later that day. 

Three months later – while on bail for the earlier incident - Beigzadeh was arrested again for doing ‘burn–outs’ in the city. During that arrest, a Samurai sword was found under the driver’s seat of his car. 

Those incidents prompted SAPOL to put warnings onto its computerised internal information-sharing system warning officers that Beigzadeh “may be armed” and suffered a “psychological/psychiatric disorder.” 

Despite that, police failed to follow up Christopher’s initial report to police. 

A Coroner’s report into Christopher’s death – handed down in 2008 – was scathing of the botched police investigation prior to Christopher’s murder. 

It outlined 49 failures of police to properly investigate not only the matter Christopher reported to police but the two other incidents involving Biegzadeh. 

“Christopher’s death could have been avoided if police had taken the necessary action,” Connie said. 

“But for the Coroner’s court, we, the public would not know – in minute detail – the acts and omissions of the police – which had they been handled differently may have prevented Christopher’s tragic, fatal shooting,” she said. 

“Police were on notice that Biegzadeh had a violent and dangerous history yet did not take the appropriate action which, in all likelihood, would have prevented Christopher’s murder. 

“That lack of action has had a devastating effect on Christopher’s family with his younger brother, Mark, taking his own life several years later as he was unable to live with what he saw the night Christopher was killed. 

“Their brave and courageous mother, Julie, has been stoic in her determination to ensure her sons’ lives weren’t lost in vain. 

“These amendments – and the government’s Bill as a whole – are testament to Julie’s brave fight for justice for her sons. 

“But it’s not just Christopher. The same can also be said of the systemic failures of the child protection system that so tragically failed to protect little Chloe Valentine. 

“The same can be said of the unsafe workplace practices that resulted in the death of Daniel Madeley, the systemic failures that failed to protect victims of domestic violence like Zahra Abrahimzadeh, the systemic failures in our health system that so appallingly failed stroke victims and resulted in the chemotherapy bungle that resulted in a call for a Royal Commission by the then Coroner. 

“Coroner’s inquiries – and subsequent recommendations - serve to prevent the same mistakes from happening again. It is the most important means of ensuring the accountability of employers, regulators and government agencies.”

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