Warning: this report refers to suicide and may be distressing for some readers.

An Australian-first research project released Wednesday has urged the establishment of a national system of accountability to ensure findings by coroners are used to inform suicide prevention measures for Aboriginal and Torres Strait Islander people.

The project report, Coronial Responses to Suicides of Aboriginal and Torres Strait Islander People, also calls for: Identified liaison roles to support Aboriginal and Torres Strait Islander families in all coroners' courts, staffed by Aboriginal and Torres Strait Islander people; Ongoing cultural training and oversight for Coroners and their staff, provided by Indigenous people; Revision of information brochures and other written communications by Coroners' courts, to make them appropriate for Indigenous people; and law reform where required to ensure Coroners consider Aboriginal and Torres Strait Islander cultural requirements, such as in establishing a person's next of kin.

Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) director Professor Pat Dudgeon, the report's lead author, said the findings "make a clear case for immediate investment in the capacity of coronial systems to respond to the needs of our people".

"It is simply unacceptable that Aboriginal and Torres Strait Islander families, who lose loved ones to suicide at more than double the rate of other Australians, have to go through a system that does not recognise their culture and that many find intimidating and alienating," she said.

Professor Dudgeon said a national system should be established to examine suicides of Aboriginal and Torres Strait Islander people, identifying patterns in the time leading up to the event and using that information to develop targeted prevention strategies, and that such a system could be modelled on the Australian Domestic and Family Violence Death Review Network, which looks in detail at all family violence deaths and makes recommendations for systemic change she said.

"The Australian Bureau of Statistics last week released data showing Indigenous suicides were at their highest rate ever in 2022 and have continued to rise for well over a decade," she said.

"It is time for all jurisdictions to acknowledge that Aboriginal and Torres Strait Islander suicide is a crisis, and respond accordingly by investing in the solutions proposed in our report."

Professor Dudgeon noted that the recommendations could play a part in preventing future suicides by: Identifying emerging Indigenous suicide trends, so they could be addressed through prevention measures; Better supporting families and communities at a time of profound distress, to reduce the likelihood of additional "cluster" suicides; and more accurately identifying Indigenous suicides, which the ABS says may be under-reported, and advocating for fair funding based on the real impact.

Professor Dudgeon said it was encouraging that coroners recognised the need for their courts to improve their cultural capacity to respond to Aboriginal and Torres Strait Islander families.

"Many coroners mentioned the same issues identified by Indigenous family members, but their hands are tied by inadequate funding and inflexible legislation," she said.

"I hope that our report encourages governments to invest in the system so our people have better experiences and coroners and their staff can develop the skills they need."

The most up to date data shows a severe disadvantage faced by Indigenous people in terms of suicide. Aboriginal and Torres Strait Islander people take their lives at twice the rate of other Australians. For children and youth, the rate is four times as high.

Indigenous suicides are linked to intergenerational trauma and continuing disadvantage, including poverty, homelessness, incarceration, child removal, domestic violence, lower access to education and employment, and systemic racism.

239 Aboriginal and Torres Strait Islander people died by suicide last year – the highest number ever reported

Suicide is the 2nd leading cause of death for Indigenous males, and 11th for non-Indigenous, and it is the 10th leading cause of death for Indigenous females – 26th for non-Indigenous females.

The CBPATSISP's report is based on the perspectives of Aboriginal and Torres Strait Islander people who have been bereaved by suicide, and on interviews with coroners, community organisations and others with a personal or professional interest in Indigenous suicide. This included a workshop with Aboriginal and Torres Strait Islander family members who have lost loved ones to suicide, convened in collaboration with the Aboriginal and Torres Strait Islander Lived Experience Centre (ILEC), part of the Black Dog Institute (BDI).

The lived experience group also developed a companion report, which is also published today as part of the research.

Aboriginal and Torres Strait Islander Lived Experience Centre head Vicki McKenna said it was essential to ensure families' experiences were conveyed directly, in their own words.

She noted the workshop group members had gone through, "an enormous emotional journey, sharing their lived experience through this research with the possibility of shaping how the coroners' courts respond to Indigenous people in future".

"Members of the workshop group told us the coroners didn't really understand their culture and didn't always show respect," Ms McKenna said.

"They didn't know about men's and women's business or our practices and rituals after someone has passed away. Some of the group said they found the whole process intimidating. The coroner is a court, and lots of our people have had bad experiences with courts."

Ms McKenna said coroners should learn about the culture of the communities in their state or region, meeting Elders and make a connection with them, using appropriate language and having welcoming spaces.

"People want their loved one's life to matter. We want their passing and everything that happened at the time to be used to prevent other suicides," she said, adding that the Victorian Coroner's Aboriginal Engagement Unit has implemented many measures to support Indigenous families and assist the coroners in investigating Indigenous passings, and could provide a template for other jurisdictions.

"Now it is up to governments to fund coroners' offices so they can implement these reforms," she said.

National Indigenous Times has contacted the federal government for comment.

The Coronial Responses to Suicides of Aboriginal and Torres Strait Islander People research program was funded by the National Suicide Prevention Office.

The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) was established in 2017 to develop and share evidence about effective suicide prevention approaches for Indigenous people and communities.

CBPATSISP is based at the School of Indigenous Studies at the University of Western Australia, and funded by the Commonwealth Department of Health and Aged Care.