Introduction

Suicide rates reflect the health of the social body; thus, a traumatized and damaged community may have high rates of suicide (Tait and Carpenter 2015). According to the Australian Bureau of Statistics, Indigenous Australians are more than twice as likely to commit suicide than non-Indigenous Australians, with a ratio of 25.5 per 100,000, compared to only 12.7 per 100,000 for non-Indigenous Australians (ABS 2017). This rate disparity has also been increasing over time (DeLeo et al. 2011). As a consequence, Indigenous suicide remains a focus of government policy and funding, with AU$19.6 million provided in the Australian Federal Government Budget in 2019 and a further AU$12.5 million earmarked for 2020 to support projects which aim to make health programs for Aboriginal and Torres Strait Islander people more effective (LNP 2019).

Research also continues at pace. For example, in a systematic review of the literature on Indigenous youth suicide, Harder and colleagues (2012) found 771 papers; Clifford (2013) identified 1339 references to suicide prevention of Indigenous people; and in systematic review of the global incidence of suicide among Indigenous peoples, Pollock and colleagues (2018) included 13,376 relevant papers. This has led Whittaker (2018a, b) to conclude that Indigenous people are among the most researched in the world, but that such levels of knowing do not result in changes in their circumstances. In Australia, for example, government health initiatives focused on reducing these rate-disparities, such as “closing the gap” campaigns, have had little tangible impact over the past ten years—with “mortality and life expectancy gaps actually widening” (Australian Human Rights Commission 2018).Footnote 1 One of the reasons that campaigns, such as “closing the gap,” fail is that they continue the portrayal of Indigenous lives in academic research and social and government policy as one of dysfunction (Klein and Razi 2018: 88). In this way of thinking, it is Indigenous people who are positioned as the “authors of their own misfortune” (Cunneen 2018: 29). Such pathologizing of Indigenous peoples and their communities ignores how these problems have emerged from colonial policies and, as such, require structural, not individual, solutionsFootnote 2 (Watson 2011). As Cunneen (2018: 30) reminds us, overcrowded housing, higher suicide rates, high infant mortality, and chronic poor health did not “fall from the sky”; rather, they were “created through policies such as dispossession, forced relocation, and the removal of children.”

The idea that Indigenous Australians cannot produce a workable response to their own disadvantage, or that Indigenous communities are unable or unwilling to govern themselves and that it is up to non-Indigenous Australians to intervene in their lives to ensure their “wellbeing,” reflects a colonial logic that positions Indigenous Australians as “other” (Bielefeld 2018). Through this process, Indigenous people, as the colonized group, are considered inferior to, less civilized than, and somehow lacking in comparison to the colonizing group—a portrayal that persists long after the initial act of colonization has ceased (Sherwood 2013). This article explores the assertion that coronial inquiries into Indigenous suicide “fall into the same patterns of creating Indigenous subjects of disadvantage rather than doing the crucial work of interrogating colonial relations” (Whittaker 2018a: 33).

Method

This article is informed by a threefold method. The first part, described in the first section of the findings below (“Coronial Reflections on Suicide Decision-Making”) was based on interviews with thirty-two coroners from all states and territories in Australia, except Tasmania. Selective sampling was the basis for coroner involvement, and while it is often suggested that judicial officers are reluctant to be interviewed—on the grounds that the law rather than the officer is responsible for a legal outcome (Pierce 2002)—this was the case only in Tasmania, where access to coroners was denied by the Chief Magistrate.

The coroners who formed part of this study ranged in their professional experience from twenty years to six months. The sample consisted of fourteen female coroners and eighteen male coroners, located in both rural and urban areas. The interviews were treated as an informal social encounter, understood as producing knowledge rather than simply recording it with the interview, itself, a process of meaning making between the coroner and the interviewer. This was aided by the fact that all interviews were conducted by two academics with long-standing expertise in the coronial jurisdiction. This interaction leant itself to a relationship of trust through shared knowledge, relationships, and experience within the sector. Ethical protocols supported this conversational technique and coroners were offered the opportunity to review their transcripts and redact any elements of the conversation. At this point, one coroner decided not to continue with the project.

We used thematic analysis in this research and favored an inductive approach to the data we gathered from the interviews and the inquests (Braun and Clarke 2006). We identified key themes through a series of discussions between members of the research team, making note of dominant and emergent patterns and then reviewing them. Importantly, a “key theme” does not necessarily depend on a “quantifiable measure” but on whether it captures something significant in relation to the overall research questions. In the context of the interview data, the key themes identified included Indigenous cultural difference as an explanatory tool, the implications of social disadvantage, and the capacity to form the requisite intent. These hinted at a deep colonial narrative.

The second part, described in the second section of the findings below (“Coronial Inquests and Their Recommendations”) began with the identification during interviews of four inquests performed by coroners in Western Australia (WA). These inquests occurred over a period of ten years—from 2008 to 2017—and involved the investigation of the deaths of forty-five Indigenous people in communities in the remote Kimberley region of the state. Thirty-five of these deaths were found to be suicides, and seventy-nine recommendations were offered by the presiding coroners.Footnote 3 Two points are worth noting here to demonstrate both the rarity of these inquests, and their importance in the landscape of coronial investigations into Indigenous suicide. First, an inquest is a public inquiry and most inquests investigate a single death. Between 2000 and 2009, only five “joint inquests” were held in WA, and this figure includes the two 2008 inquests in this research (Law Reform Commission of Western Australia 2010: 20). Similarly, coronial recommendations are not an obligatory outcome of a coronial investigation, and they tend to occur in the minority of coronial investigations. Between 2000 and 2009, 565 recommendations were made by WA coroners (Moore 2016), and in the same time frame, 15,701 coronial deaths were investigated and 422 inquests held (Law Reform Commission of Western Australia 2010). The inquests investigated here appear to be unprecedented, with no other coronial jurisdictions in Australia initiating such wide-ranging investigations into the lives of Indigenous people in the past twenty years. These inquests thus offer a singular and public insight into the “soft law” of the coronial jurisdiction as a colonizing force (Westerman 2020). The inquests occurred in the following order:

  • Inquest 1 took place in 2008 and examined the deaths of twenty-two Aboriginal people across the Kimberley region whose ages ranged from seven to forty years. The deaths occurred between 2000 and 2006, and fifteen were found to be suicides. The inquest was presided over by State Coroner Alastair Hope, who made twenty-seven recommendations (Hope 2008a).

  • Inquest 2 also occurred in 2008 and examined the deaths of five Aboriginal people in the small Aboriginal community of Oombulgurri in WA. Their ages ranged from fifteen to forty-one years. The deaths occurred between 2005 and 2006, and four were found to be suicides. The inquest was presided over by State Coroner Alastair Hope, who made five recommendations (Hope 2008b).

  • Inquest 3 occurred in 2011 and examined the deaths of five young Aboriginal men and children in the Balgo Aboriginal Community. Their ages ranged from thirteen to twenty-two years. The deaths occurred between 2008 and 2010, and four were found to be suicides. The inquest was presided over by State Coroner Alastair Hope, who made five recommendations (Hope 2011).

  • Inquest 4 occurred in 2017 and examined the deaths of thirteen Aboriginal children and young people in the Kimberley region whose ages ranged from ten to twenty-four years. The deaths occurred between 2012 and 2016, and twelve were found to be suicides. The inquest was presided over by the State Coroner Rosalinda Fogliani, who made forty-two recommendations (Fogliani 2017).

These recommendations were analyzed thematically in order to investigate the validity of the findings from the coronial interviews, testing the reflections offered by coroners with their actions in court, and seeking explanations. Three key themes emerged from our examination of the inquest recommendations: the invocation of a pathologizing narrative of alcohol abuse; a paternalistic approach to parenting; and a focus on Indigenous people as “deficit Indigenes” (Walter and Anderson 2013: 21)—failing subjects of modernity who need to be raised to the non-Indigenous standard through an emphasis on “closing the gap.” Given the small number of inquests identified during the interviews, however, a third element of the method was required, in order to triangulate our findings.

The third part, which we outline in the third section of the findings below (“Cluster Inquests and Colonial Decision-Making”) was based on a thorough search of all coronial inquest records on suicide available on government websites in AustraliaFootnote 4 between the period of January 2000 and December 2019. Its purpose was to discover if other jurisdictions had investigated Indigenous suicide in the manner identified in WA, and, if so, to determine the existence of a colonizing narrative. Cases were included when two or more people were the subject of an inquest where the outcome was suicide. Both Indigenous and non-Indigenous deaths were included to enable a comparative analysis of any differences in impetus or outcome.

Due to the lack of a national database in Australia or any consensus in the reporting of coronial inquests, we searched each state and territory’s Coroner’s Court website individually.Footnote 5 From the relevant inquests, we cross-checked each case file against a series of keywords (e.g., suicide, Indigenous, Aboriginal). Findings from across Australia were also cross-checked via media searches through a generic Google search for each state, using keywords such as “Indigenous,” “inquests,” “suicide,” and “suicide clusters.” In addition, we used the international news database, Factiva (https://global.factiva.com/), to ensure that all major inquests of public concern had been identified.

Four Indigenous inquests and thirty-five non-Indigenous inquests across Australia met the criteria for inclusion in the twenty-year time frame: in Queensland, there were two Indigenous and nine non-Indigenous inquests; in the Northern Territory, there were one Indigenous and two non-Indigenous inquests; in South Australia, there were no Indigenous and nine non-Indigenous inquests; in the Australian Capital Territory, there were no relevant inquests; in Victoria, there was one Indigenous and one non-Indigenous inquest; in New South Wales there were no Indigenous and ten non-Indigenous inquests; and in Tasmania, there were no Indigenous and four non-Indigenous inquests. Again, findings were analyzed thematically and we identified a colonizing approach in the inquests of Indigenous people, with a continued focus on substance abuse and its impact on mental illness and community contagion. Alongside these, however, we noted a new narrative which positioned Indigenous culture as a key problem in the fight against Indigenous suicide, thus deepening the colonial narrative.

Findings and Discussion

Coronial Reflections on Suicide Decision-Making

Coroners are the only persons tasked with making routine legal determinations of suicide in Australia, Canada, New Zealand, the United Kingdom, and the United States (De Leo et al. 2010; Jowett, Carpenter and Tait 2018; Ozanne-Smith and Pearse 2009; Walker, Chen and Madden 2008). Our previous research has made four general findings which are important for helping to contextualize the process of suicide determination for Indigenous Australians. First, as is the case in criminal justice, the deaths of Indigenous people are more likely to be investigated by coroners than those of non-Indigenous people, thus making them over-represented in the coronial jurisdiction (Carpenter and Tait 2009). Second, coroners will avoid making a finding of suicide wherever possible due in part to stigma and family resistance (Carpenter et al. 2015b, a; Tait and Carpenter 2013). Third, coronial decision-making is contingent upon a range of diverse factors (experience, location, personality, training), which impacts the standard of proof required.Footnote 6 Finally, none of the eight state Coroners Acts include a standard definition of “suicide,”Footnote 7 and coroners rely on a range of definitions from a variety of sources (Jowett, Carpenter and Tait 2018). Within this general framework, some specific observations about Indigenous suicide became apparent in the interviews with coroners, which speak to the differential ways that suicide is determined on the basis of racial and ethnic identity. These include: (i) the diverse risk factors for suicide expected for Indigenous Australians in comparison to non-Indigenous Australians; (ii) the role of social disadvantage in supporting findings of suicide for Indigenous people; and, (iii) the lower standard of proof for capacity required by coroners when the deceased is Indigenous.Footnote 8 These will now be discussed briefly.

Indigenous Risk Factors

According to coroners interviewed, the usual risk factors for suicide do not apply to Indigenous Australians. Whereas the normal expectations include depression, suicide notes, and previous attempts, these factors appear far less relevant for coroners when considering the suspected suicide of an Indigenous Australian.

I wouldn't dream of looking for a suicide note in an Aboriginal person, that would be just craziness because they never do that so why would you look for that. (Coroner 10)


But interestingly, you’re not going to find an Aboriginal suicide where they’re—well, some of them, I’m generalizing—but most of them are not on anti-depressants and they don’t have a history of mental illness and they haven’t been treated generally. (Coroner 25)

This appears to be based on an understanding that Indigenous suicides are triggered far more easily than non-Indigenous suicides: that they can occur after minor disagreements, arguments or disappointments; that they are not necessarily accompanied by previous self-harm; and that they are often entirely unanticipated by their family and community as a spur of the moment action.

The other thing I noticed was that they required far less of a trigger for suicide than perhaps the [Australians with] European [heritage] community. (Coroner 18)


It’s becoming the norm and it is—it’s triggered. It’s very easy. People flip that off the tongue. I'm going to kill myself. (Coroner 24)

Understanding Indigenous suicide as intrinsically different from non-Indigenous suicide also gives coroners permission to make disparate determinations of suicide. Research does support this understanding (Hansen 2011; Hunter and Milroy 2006; Tatz 2005; Tighe et al. 2015) and yet, given that much of the research and analysis, at least in the countries under consideration, is based on suicide data gleaned from coronial files and databases, there appears to be a feedback loop between the determinations, the data and the conclusions drawn by researchers. This suggestion of a “feedback loop” between researchers and coroners was first identified by Atkinson (1978: 144), who suggested that academic explanations of suicide were nothing more than “formalized versions of the informal ones used by coroners” and that “an acquaintance” with suicide research “might [also] lead them [coroners] to feel surer about the kinds of cues used in inferring intent.” We suggest that this feedback loop continues when social disadvantage is considered by coroners as a context to suicidal intent.

Perceptions of Social Disadvantage

Australian coroners appear to have conventional and ill-informed ideas about Indigenous life and culture. One outcome is that suicides can be positioned as more understandable to coroners, given their social circumstances. This relationship between social and material deprivation and suicide appears heightened for coroners when Indigenous communities are considered, given their known disadvantaged social and economic status.

If you look at the cohort of Aboriginal people who commit suicide, they have to be in that hopeless, helpless situation. They've had appalling upbringing, for whatever reason. (Coroner 27)

The way that some people live or are forced to live, is so destructive from the start, and self-destructive with drugs, mental illness, broken homes, that sort of stuff, domestic violence, whatever. It just seems to be the accumulation, really the end point, it was always going to happen. (Coroner 26)

This has the potential to lead to a circular reasoning that supports our suggestion that suicide statistics are, in part, the creation of the coroner and thus influenced by the logic of colonialism. Of course, such a suggestion is not new and sits within a larger tradition within the sociology of deviance, and debates within criminology on the validity of officially derived data (Atkinson 1978: 63). This research, however, makes the further suggestion, following Atkinson (1978: 172), that it is “not simply a case of asking whether a particular death could have been a suicide, but of asking whether that particular person could have committed suicide … assessing how far suicide would be a possibly appropriate end to a person’s biography.” We contend that the perception that Indigenous people have terrible lives contributes to an expectation of suicide, which leads to higher Indigenous suicide rates, which increases the perception that Indigenous people have terrible lives. We argue that such a logic may, in part, be responsible for the disparity of suicide rates between Indigenous and non-Indigenous people. For coroners, suicide appears a “more appropriate end” for Indigenous people than for non-Indigenous people whose similar deaths may be more likely characterized as an accidental death or one of misadventure.

Capacity

In order to reach a finding of suicide, the individual concerned must be deemed by the coroner to have the capacity to understand the implications of his/her/their actions (Jowett, Carpenter and Tait 2018). The notion of capacity, however, appears to work differently according to whether or not an individual is Indigenous. Alcohol, for example, is often used to discount suicide for non-Indigenous Australians by supporting the assertion that they were too drunk to know what they were doing (Linsley et al. 2001). In such situations, the death may be recorded as accidental or as a misadventure. Coroners interviewed for this research also positioned alcohol as diminishing intent in non-Indigenous suicides (Jowett, Carpenter and Tait 2019). When coroners were asked to reflect on any patterns associated with Indigenous suicide, however, they often raised the role of alcohol in the death.

If there is a pattern, it’s alcohol, more than anything else. In the sense that they get really charged up. (Coroner 2)

… but that’s what you do in certain circumstances when you’re unhappy and someone is against you and you’ve been drinking alcohol and you go do it. (Coroner 25)

Research also suggests that recorded Indigenous suicide has a higher history of alcohol and substance use than non-Indigenous suicide, with alcohol implicated in 77% of Indigenous suicide deaths in the Northern Territory (DeLeo et al. 2011). This supports our premise that what coroners determine to be a suicide is what is counted as suicide in the official data.

A similar issue is raised with respect to age. Coroners were very reluctant to reach a finding of suicide when investigating the deaths of young Australians based on the argument that these individuals are incapable of fully understanding their actions (Jowett, Carpenter and Tait 2019; Martin 2015).

But in my position, it’s the evidence that’s available, and the young child is harder to satisfy yourself that they appreciate the significance of death—they can properly conceive death—and therefore you can’t get the evidence to satisfy yourself that they intended to take their own life. (Coroner 8)

This logic is not as readily applied to the death of young Indigenous children.

I still think many children are in such a devastatingly terrible place that they don’t want to live. (Coroner 27)

There seems to be less of a cultural issue in relation to kids killing themselves or anyone killing themselves really … the stigma that our society feels, doesn’t exist at all. (Coroner 12)

Despite making up less than three percent of the population, Aboriginal and Torres Strait Islander children and young people represent 28.1 percent of the suicide of deaths by children under the age of eighteen (Mitchell and Gooda 2015). Once again, this lends support to our premise that these statistics are, at least in part, an outcome of the suicide determination of coroners.

When Razack (2015: 4) investigated the coronial inquests of Indigenous people in Canada who had died in police custody, she encountered stories of alcoholism, fatty livers, and mental illness rather than an “interrogation of violence.” She argued that such a focus on individual pathology made it difficult for Indigenous people to “interrupt the narrative of their dysfunction” (Razack 2011b: 93). Such a focus also appears in our research, with suicide deaths related to how they live, where suicide is less of a cultural issue in relation to kids killing themselves, and inevitable because they’ve had appalling upbringings. For Razack (2011a), this focus on dysfunction hinted at a deeper colonial narrative—the difficulty that Indigenous people face in coping with modern society—that it was always going to happen. A population damaged by alcohol abuse, for example, will necessarily experience untimely deaths. In a drunken death, no-one is to blame because that’s what you do … when you’re unhappy and someone is against you and you’ve been drinking alcohol.

Such decision-making appears to do two things: it continues to pathologize the behavior of Indigenous people, with alcohol abuse situated as an inherent pathological frailty; and it positions Aboriginal people in a “deficit model” of modern citizenship, which is a shorthand for the inability of Indigenous people to overcome their status as “primitive outsider.” In this way, it erases the impact of colonialism, by focusing on the alleged failings of the individual, rather than the political and structural elements of history. These colonial practices will now be explored in more detail through an examination of four inquests held in WA between 2008 and 2017. We contend that the reflections evident in these in-depth conversations, and which hint at the invocation of a deep colonial narrative, become clearer when the court practices of the coronial inquest are investigated.

Coronial Inquests and Their Recommendations

According to Scott Bray and colleagues (2018), the modern coronial role in Australia is focused on death prevention, which has been enshrined legislatively as a key part of the coroners’ core duties from the mid-1980s. This shift in coronial attention from crime to public health, and from criminal concepts (such as culpability) to the social purpose of preventable death, is encapsulated in the statutory power of coroners to make recommendations for reform to government agencies and policy makers. While all Australian coroners possess the power to make recommendations, mandatory responses are required in only some jurisdictions (Scott Bray 2010, 2018). Although this has led to concern about the amount of coronial insight potentially stockpiling without consequence (Scott Bray 2008), we assert that there is a need to examine the nature and quality of coronial recommendations emerging from inquests investigating Indigenous suicide, including an analysis of their racializing statements and reiteration of a deficit discourse.

The promise of the coronial recommendatory role was highlighted by the Royal Commission into Aboriginal Deaths in Custody (RCIADIC), which identified “the pervasive and troubling failure” of the coronial system to uncover the circumstances of Aboriginal deaths in custody and to make appropriate coronial recommendations (Watterson, Brown and McKenzie 2008: 6). As a consequence, RCIADIC made thirty-four recommendations aimed at modernizing the coronial system and enhancing its preventive potential including a more “positive duty” to be imposed on coroners, and an upgrading of coroners’ recommendatory powers from discretionary to obligatory (RCIADIC 1991: [4.5.89]). This has yet to occur (Scott Bray 2016), and while many of the recommendations from the RCIADIC remain unimplemented, this is been accompanied by hundreds of further unimplemented recommendations into Indigenous lives, including Bringing them Home (1997), The Little Children are Sacred Inquiry (2007), and Royal Commission into the Protection and Detention of Children (2017). This has prompted Whittaker (2018a, b: 26) to ask, “To what end has this knowledge been produced?” We would like to take seriously Whittaker’s question and focus the rest of the discussion in this article on the ways in which “soft law,” particularly coronial investigations into Indigenous suicide, have contributed to the ways in which Indigenous suicide is known, and thus to the ways in which it might be prevented.

While the officially stated reasons for the four inquests were straightforward and resolved to investigate the over-representation of Aboriginal people—and, more specifically, children and young persons, in suicide in the Kimberley region—they were precipitated by a range of other matters that underpin a colonizing approach by the coroners. The impetus for Inquest 1 was an approach to the State Coroner by the Chairman and Co-Director of the Kimberley Aboriginal Law and Cultural Center (KALACC) linking the death rate to the “abuse of alcohol in the Fitzroy valley” (Hope 2008a: 1). The initial suggestion for Inquest 2 came from the Officer in Charge of Wyndham Police Station, Sergeant Thompson, who raised a number of concerns with the State Coroner including: that the community was dysfunctional and lacking in governance; that anecdotal information suggested sexual abuse was rife in the community; and that an excessive amount of alcohol was consumed in the community (Hope 2008b).

While Inquest 3 was informed by concerns about a cluster of suicides occurring in the small Balgo Aboriginal community in WA, the State Coroner also identified the vulnerability of and lack of resilience in the young men who had died. Based on his observation that suicide stems from the interaction of personal vulnerability factors and situation factors, Coroner Hope observed that in the cluster at Balgo the “immediate situational factors were relatively minor.” This suggested to him that the “personal vulnerability factors of the deceased persons played the greatest part” in the deaths and raised the questions as to why the “resilience of the young men concerned was so low” (Hope 2011: 5–6).

The deaths of thirteen children and young people were investigated together in the final inquest, due to the similarity of the “circumstances, life events, developmental experiences and behaviors that appear to have contributed to making them vulnerable to suicide” (Fogliani 2017: 8). This collective focus enabled these “tragic individual events” to be understood as the result of “the crushing effects of intergenerational trauma and poverty upon entire communities” (Fogliani 2017: 8). In order to take account of the “longitudinal impact of the traumatic events,” the inquest resolved to inquire into their “physical health, medical history, home environments, mental health treatment, school attendance” (Fogliani 2017: 8).

Perhaps unsurprisingly, these stated concerns for vulnerable people, suffering alcohol abuse, living tragic lives, and lacking resilience do not challenge concerns about a deep colonial narrative evident in the coronial jurisdiction.

Alcohol and Substance Abuse

Of the seventy-nine recommendations offered across the four inquests, twenty-three recommendations (almost 30%) placed alcohol control at the center of a suicide prevention approach—with a focus on legislation to decrease access to alcohol, to increase policing, and to restrict access to welfare—all of which demonstrate the paternalism inherent in a colonial narrative which presumes both a pathological frailty and an inability to self-govern.

Legislation

All inquests included recommendations to restrict access to alcohol in the specific Aboriginal community which was the subject of the inquest. For example, the first recommendation of Inquest 2 suggested that the Liquor Control Act 1988 (Western Australia), which already restricted the purchase or consumption of alcohol in certain Aboriginal communities, be extended to Reserve Area 3960, the community of Oombulgurri. Similar recommendations were repeated in Inquest 4, where Recommendation 9 advised the WA government to assess the feasibility of a Banned Drinker Register, while Recommendation 2 of Inquest 2 proposed limiting access to full strength takeaway alcohol in the Kimberley region through invoking legislative restrictions already in place in other Aboriginal communities. Recommendation 1 of Inquest 3 advocated the implementation of the Volatile Substance Prevention Act 2005 (Northern Territory) in WA to enable involuntary treatment orders to be made in Aboriginal communities.

Policing

With an emphasis on legislative and regulatory change, it should not come as a surprise to learn that many of the recommendations supported an increased police presence. For example, Recommendations 10 and 11 in Inquest 4 suggested further resourcing of police to enforce the amendment to the Liquor Control Act, and Inquest 2 advised conferring increased police powers to seize and dispose of alcohol found in restricted communities. Recommendations 25–27 in Inquest 1 proposed resourcing for an increased police presence in remote Aboriginal locations in order to coordinate the alcohol and drug regulatory response for the Kimberley district.

Welfare Restrictions

A focus on welfare restrictions in Aboriginal communities invokes both the paternalism of a colonial narrative and positioning Aboriginal people as failing as capable modern citizens—both overlaid with that inherent pathological frailty of the dysfunctional alcoholic body. Voluntary cashless debit cards for welfare recipients were advocated in Recommendation 22 of Inquest 4, and compulsory income management was suggested in Recommendation 11 of Inquest 1. Voucher systems for welfare payments were offered as an option in Recommendation 2 of Inquest 2 in order to limit the amount of money available for the purchase of alcohol. Interestingly, this recommendation is a reiteration of Recommendation 20 of Inquest 1.

This focus on alcohol abuse and control as the key feature in a suicide prevention strategy supports Razack’s (2011a: 353) assertion that Aboriginal people are represented consistently as “possessing an inherent pathological frailty that is more often than not associated with alcohol abuse.” This medicalizing discourse maintains a focus on the sick Aboriginal body (and mind) and works to discredit other discourses like racism, or colonialism (Bielefeld 2018). Razack (2011a: 352) positions such a representation as related to the process of othering, with Aboriginal people seen as having a “tenuous hold” on, and unable to enter, modern life. Damaged and dying, they “cannot be entrusted with self-governance.” Those unable to govern themselves are “undeserving citizens”—childlike and incapable of managing their money, their families, or themselves.

Protection of Children

Given that three of the four inquests were concerned, in particular, with the high numbers of children and young people taking their own lives, twenty recommendations (25%) responded to these concerns in detail, with a focus on parental responsibility, truancy, and the need for government leadership in these “failing” communities.

Parental Responsibility

A focus on the alleged failings of bereaved Aboriginal parents was apparent in the inquests which recommended a range of monitoring and sanctions. For example, a concern with fetal alcohol syndrome disorder (FASD) as a cause of suicide in young people led Inquest 4 in Recommendation 1 to encourage universal screening for FASD during infant health checks in Aboriginal communities. Recommendation 4 of Inquest 3 suggested that repeated non-attendance at school by children invokes both the School Education Act 1999 (Western Australia) and the Parental Support and Responsibility Act 2008 (Western Australia).

Truancy

A number of recommendations were concerned, in particular, with school absenteeism in Aboriginal communities. The approach of the inquests was to increase surveillance and/or offer punitive sanctions against parents. For example, Recommendation 13 of Inquest 1 advocated monitoring the truanting child and implementing a “range of government resources to be applied to addressing the issue,” while Recommendation 3 of Inquest 3 suggested income management be considered for the parents of truanting children.

Government Leadership

A number of recommendations focused particularly on the perceived lack of leadership in these communities and the need for government to step into the vacuum. For example, Recommendation 3 of Inquest 2 suggested an increased presence of police and child protection agents in Aboriginal communities, while Recommendation 7 of Inquest 4 advised the state government to appoint a special advisor on matters concerning Aboriginal young people and children. The first recommendation in Inquest 1 also proposed the appointment of an individual with the power and resources to make decisions and coordinate responses to the “disaster” of Aboriginal health in the region. This was reiterated in Recommendation 5 of Inquest 2.

According to Cunneen (2019: 34), such recommendations are aligned closely with the rise of “new paternalism,” which is aimed at changing the behavior of welfare recipients through government oversight and coercion. Positioned as “functionally inept” and “likely to indulge in risky behaviors,” this stigmatization of welfare recipients focuses attention on individual failings and family dysfunction, and a failure to demonstrate responsibility initiates more punitive interventions and threats (Bielefeld 2018: 752; Cunneen 2019: 38). Moreover, Indigenous people and their communities are “ripe targets” for new paternalist policies “because of long-standing colonial narratives,” which have required “Indigenous culture to fit with the demands of colonial governance.” This new paternalism also relies on framing Aboriginal identity in “a narrative of deficiency” (Cunneen 2019: 35).

Closing the Gap

This narrative of deficiency was evident in two of the four inquests, where seventeen recommendations (21%) centered on the deprivation of Indigenous people in these communities, focusing on housing, education, and employment. Inquest 1 took an inherently paternalistic approach. In contrast, Inquest 4 overlayed “culture” on disadvantaged individuals, communities, and families as the way to counter deaths by suicide. Inquests 2 and 3 were silent on these measures.

Housing

Inquest 1 focused on the poor state of public housing. It was determined that the disrepair was due to a lack of capacity in Aboriginal inhabitants to manage their domestic life. It was suggested that this problem could be solved by linking successful completion of a homemaking program with access to housing. For example, Recommendation 18 suggested that public housing includes basic furniture, but only after the occupants had been “adequately educated in respect of the need to look after the properties and any furniture.” Such education was outlined in Recommendation 19, which focused on “life skills ... to maintain homes provided to them in clean and hygienic ways.” Satisfactory completion of the program was the only way to access a new home. Nine years later, Inquest 4 focused more on the provision of public housing that was “culturally appropriate” (Recommendation 13), funded in the long term (Recommendation 14), and not “means tested” (Recommendation 15). It is worth noting that Inquest 1 also suggested the need for culturally appropriate housing, “particularly when [such] alternatives provide a less expensive option” (Recommendation 17).

Education

Inquests 1 and 4 were most focused on the role of education in addressing the alleged deficiencies in Aboriginal citizenship. Aside from a focus on truancy, Inquest 1 was supportive of remedial teaching (Recommendation 14), while Inquest 4 suggested education campaigns in secondary schools to alert students to the dangers of consuming alcohol during pregnancy (Recommendation 6). Outside this deficit model of education, Inquest 4 made a number of recommendations that placed culture within education as key to prevention of suicide, including teaching of Aboriginal languages (Recommendation 38), Indigenous-specific early childhood programs (Recommendation 35), and support of projects which connect troubled youth to culture and tradition (Recommendation 39).

Employment

When engaging with the employment of Indigenous people in these remote communities, both Inquests 1 and 4 struggled to offer recommendations that did not invoke a colonial narrative of deficiency, or paternalism, or both. For example, in Inquest 1, Recommendation 3 maintained that “positive action should be taken, where practicable, to employ Aboriginal people [noting that] this may require upskilling,” while Recommendation 4 proffered that “Aboriginal leadership should be encouraged where suitable leaders can be found.” Recommendation 10 discussed how important it was that government services are not disadvantaged in attracting non-Indigenous staff to the Kimberley. In Inquest 4, Recommendations 12 and 21 advocated for “efforts to continue to be made” to employ Aboriginal people in a range of government services, while Recommendation 19 supported cultural competency training to “involve local Aboriginal people.”

“Closing the gap” is a deficit-based approach that works to produce ideas of Indigenous dysfunction. Indigenous people are presented as failing citizens who need to be “raised” to the non-Indigenous standard—both socially and economically (Bielefeld 2018). Connecting Indigenous people with their culture is offered as a recommendation for prevention for suicide, at the same time that Indigenous peoples’ culture is seen as a key explanation for the problem. This is encapsulated by Coroner Fogliani (2017: 361, 299), who in presiding over Inquest 4, identified that a mismatch between Indigenous culture and the modern world was at the heart of the suicide problem when she stated that: “Aboriginal people are caught between trying to connect with their culture and trying to fit into the western world,” and cultural programs can “equip them with the skills and resilience to cope with contemporary society.” For Razack (2011a: 374), such invocations to exercise cultural sensitivity are nothing more than “banal courtesies,” positioning such recommendations amidst a “killing indifference” to Aboriginal lives and deaths (see also Bond et al. 2020; Westerman 2020).

Cluster Inquests and Colonial Decision-Making

In the forty inquests across Australia that investigated the suicide of two or more victims, the vast majority focused on the deaths of non-Indigenous Australians. A comparative analysis of the reasons for these inquests and their findings are thus instructive for this discussion. Three of the four Indigenous inquests determined that the suicide deaths were related to substance abuse and/or poor mental health connected to substance abuse and one to exposure to suicide in their community. While the inquests into non-Indigenous suicide also concluded that mental health issues were paramount in eight cases, they were never linked with substance abuse and in only one case was substance abuse considered in the context of the suicide. The inquests into the suicides of non-Indigenous people were much more likely to focus on suicide deaths in custody (15), suicide deaths related to domestic violence (7), and murder suicides (9).

These inquests clearly speak to a differential approach to the suicide investigations of Indigenous and non-Indigenous people, highlighting the pathologizing narrative of the Indigenous inquests. This aligns with the findings from the reflective conversations with coroners, who positioned alcohol as diminishing the capacity for intent in non-Indigenous people, but it also connects with the WA inquests, which focused on personal factors like substance abuse, vulnerability, and trauma over and above situational factors.

In these inquests, however, the problem of culture was also identified in Indigenous suicide deaths and hinted at in the WA inquests and the coronial interviews. This can be demonstrated most clearly in the inquest into the cause and circumstances of the deaths of Charles Edward Barlow, Patrick Douglas, and Emily Jane Baggott. Only Charles Edward Barlow was identified as Indigenous, and this offered a comparative analysis of Indigenous and non-Indigenous deaths, free of any biases that may be associated with using a sample from a range of inquests presenting the views of different coroners.

The reason for the initial inquest was to address any failure of the mental health system in relation to their deaths. The reasoning underpinning the findings of suicide differed significantly, however. Alongside the usual focus on personal vulnerability factors, such as substance abuse and disadvantage, the idea that Indigenous culture itself might also help understand the death of Charles Barlow was raised:

His failure to cooperate, attend appointments and comply with treatment were, in Professor Hunter’s view, treated by the mental health professionals as a choice Charles was making, rather than being seen as the result of an inability, perhaps because of his Indigenous culture, to comprehend recovery, understand its requirements, commit to a process and sustain that commitment. [Queensland Courts 2006 (emphasis added)]

Again, we see the contention that Indigenous people are “the authors of their own misfortune”: cultural difference is invoked to explain a range of social problems, from crime to welfare dependency, and to support a paternalistic approach to changing behavior through punishment and control (Cunneen 2019: 33). In such a context, Indigenous culture represents a failure to make the right choices—an inability to commit to a process. The idea that Indigenous culture is part of the problem of Indigenous suicide, positions Aboriginality itself as “dysfunction”—as an “incurable illness” (Razack 2011a: 374).

Conclusion

This article began by exploring the idea that how a social fact like suicide is defined and counted depends on the norms and concepts that determine what counts as suicide in a given setting or for certain purposes. After all, official suicide statistics do not measure the actual incidence of suicide, only what is counted and labeled as such. We have determined that in a colonial settler state, such as Australia, the differential way in which suicide is recorded depends on one’s racial group, but it also impacts the scrutiny of one’s death—particularly how one’s death is understood and how others can be prevented from suffering such deaths in the future.

It is the structural relations of colonialism that are the powerful determining context in inquests into Aboriginal deaths by suicide, providing an opportunity for the state to perform its legitimacy through establishing that Aboriginal people require assistance to enter modernity. They do this in a number of ways. First, by positioning Aboriginality, itself, as a pathology, the inquest transforms the colonial condition into a medical one (Razack 2011a: 374). Second, through a focus on disadvantage, Aboriginal people become the deficit subjects of their own making, requiring intervention to reach the status of a responsible citizen capable of self-governance. In a context of the unacknowledged power relations of colonialism, such efforts to “normalize” Indigenous people position them as the problem. An inability to “close the gap” between Indigenous and non-Indigenous people, for example, becomes “tied to the behavioral deficits of Indigenous people’ rather than to the failure (or lack of) government policy” (Walter and Anderson 2013: 22). Third, by focusing on culture as both the cause and the solution of high suicide rates, Aboriginality, itself, becomes the disabling condition, evident through “a mysterious incapacity to cope with modern life” (Razack 2015: 4).

It should be clear from this discussion that while inquests are inquisitorial, public, fact-finding exercises to establish the truth of a particular death, they also perform a broader meaning-making task around death. Uninterested in establishing guilt or innocence, they are instead devoted to the prevention of deaths and, in the context of investigations into Indigenous suicide, “that quintessential of colonial activities: the improvement of the colonized” (Razack 2015:7). The justice work of inquests—and of coronial investigations more broadly—is thus clearly loaded with histories (Scott Bray 2010; see also Whittaker 2018a, b).

This acknowledgment—that coronial investigations into Aboriginal suicide—or any Aboriginal death, for that matter—perpetuates the broader, ongoing legacy of settler nations, positions racialized deaths within the particular structures and institutions of the settler state, and may enable inquests to “perform an anatomy of colonialism, rather than a dissection of the sick Aboriginal body” (Razack 2011a: 374). Connecting this work with criminology will have important implications, not only for death prevention, specifically, but for criminology’s “origin stories” that have neglected the “violence of coloniality” that echoes transnationally (Carrington and Hogg 2017: 193).