Coronial inquiries were "mystifying, frustrating and disempowering" for bereaved families and they needed a lawyer to help them through the process, a new report has said.
The Federation of Community Legal Centres Victoria report said that legal representation is an international human right for the bereaved, yet families were often unaware or unable to afford it.
"Many families who have lost loved ones experience the coronial process and its aftermath as traumatic, mystifying, frustrating and disempowering," the report said.
Courts were often unclear about a family's right to legal representation, it said. When a person died in custody or as a result of a police operation, families were rarely represented. The cost was also a factor, sometimes escalating to $40,000.
Death prevention should be a stated mission for every state and territory coronial office, the report stated.
Coronial offices should be linked by a national public reporting and review scheme that would make available coroners' findings and recommendations. Each coronial office should also have staff to ensure governments were aware of and acted upon recommendations.
"Coroners may... make potentially life-saving recommendations, only for them never to be responded to or implemented, with no follow-up and no public awareness of what has happened," the report stated.
The report, Saving Lives by Joining Up Justice, launched on Wednesday, said blind cord deaths were a "tragic illustration" of governments failing to respond to preventive deaths. Infants have continued to die after being accidentally strangled or hanged due to becoming entangled in a blind or curtain cord, it said.
"Even now it is unclear whether all states and territories have implemented ongoing community campaigns and strategies to render safe those blinds and curtains that are already installed," the report said.
A non-government national inquest clearing house was needed to assist families through the inquest process, the report recommended. The clearing house could assist families with legal representation, specialist knowledge and expert opinion and help them follow coronial processes.
Where an investigation involves a death in custody, or in the course of a police operation, the report recommends that the agency conducting the investigation, at the Coroner's direction, must be practical, institutional and have hierarchical independence from the police.
It suggested a pool of funds be made available for legal support for families.