The NSW Coroners court has published findings in two inquests that may be of interest to readers of this blog:

The State Mine Fire

The Deputy State Coroner found (at [131])

… the State Mine Fire was caused on 16 October by a demolition serial conducted by ADF [Australian Defence Force] personnel at the Marrangaroo Training Area. The fire spread extensively, in particular having regard to the weather conditions over the period 16-17 October 2013, causing damage to property but no serious injury or loss of life…

After the fire the ADF held a Commission of Inquiry and the Rural Fire Service had conducted an After Action Review.  Because of these extensive reviews the Coroner said (at 12]

… there are no unresolved issues or matters which require further scrutiny or examination. There are no witnesses who have provided statements to this inquiry who should be examined. Accordingly, this hearing proceeded by the tender of the brief of evidence…

After reviewing the evidence the coroner made no recommendations or adverse comments regarding the conduct of the ADF, the RFS or of any individuals.  She said (at [131]) ‘Recommendations are neither necessary nor desirable having regard to the steps taken by the ADF, the RFS and local brigades.’

The drowning deaths of Ms King and her two children

Ms King and two of her three children drowned when her vehicle lost traction on mud and silt that had been deposited on the road by floodwater.  The vehicle left the road and entered the Tweed River.  The road had not been closed by council who were not aware of the extent of mud and silt on the road.  Multiple emergency services attended including NSW Ambulance, Police, the SES and the Volunteer Rescue Association.

The Acting State Coroner made a number of recommendations directed to Tweed Council to improve their ability to better identify the state of the roads after flood events.  Again the coroner made no adverse comments regarding the conduct of the Council or any individual.   With respect to the emergency response she said (at [50]):

I am satisfied that the Police, the SES, the VRA and Ambulance, arrived as soon as they reasonably could, given the geography and ongoing access issues, and that they did everything they could to try to rescue the family. Their work is heroic and no doubt it was an extremely challenging and difficult job for each of those individuals involved.


These events impacted upon communities and emergency service personnel and will be of interest to readers of this blog.  This blog is however about emergency law – the coronial process is a legal process so they are reported here but the findings themselves made no findings or recommendations about the law or legal issues.  The issues were questions of fact so I don’t report them in detail but leave them to interested readers to follow the links, above, and read the coroners’ findings.

Importantly members of the emergency services often cite ‘the coroner’ as the person who will criticise them and further, that someone may have to explain themselves to the coroner is used as a threat of ultimate dire consequences.

In these two events many properties and three lives were lost. These were tragic outcomes that could have been avoided.  The ADF could have chosen not to detonate ordinance on a day of high fire danger.  The Tweed Council closed roads when water was over the road but did not inspect them when the water had rescinded to determine the state of the road after the flood.  Before the coroners both the ADF and the Council identified how the event occurred, their own shortcomings and what they had done to address those issues for the future.

The coroners reviewed the events, gave a public finding as to what happened and in the case of Ms King made recommendations that are intended to help inform others in order to reduce the likelihood of future deaths in similar circumstances.

The coroners did not make adverse findings against any individual.  The coroners did not find anyone or any institution liable – that is not what the coroner is there to do.  The coroners did not find anyone guilty of any offence – that is not what the coroner is there to do.  The coroner did not recommend any disciplinary or legal action against anyone or any institution.


Further this post, a correspondent has drawn my attention to an ABC Radio National Conversations podcast Inside the Coroner’s Court (27 November 2018) in which Hugh Dillon, retired NSW Deputy State Coroner, talks about the Court and explicitly mentions how emergency services can work with the coroner.