The Quest for Coronial Recommendation: A Sought-After Voice in Malaysian Death Inquest Verdicts
Written by Benjamin Kho Jia Yuan, a final year law student of the Faculty of Law, University of Malaya.
Since time immemorial, there have been many deaths that are said to be unexpected or mysterious. Death inquests are usually done to investigate the cause of these deaths, and Malaysia is no exception in its application. However, there seems to be a reluctance on the part of Malaysia's coroners to help beyond giving their verdict during the inquest.
I. INTRODUCTION
American author Lois McMaster Bujold has a famous quote — ‘the dead cannot cry out for justice; it is a duty of the living to do so for them’.[1] Over the years, the unfortunate deaths of Muhammad Adib, Nora Quoirin, Mohamad Thaqif, Teoh Beng Hock and many more, have left indelible memories with many of us. Notably, faith and trust in death inquests[2] have always been instilled in our rakyat, purportedly as a tool to bring justice to the dead.
The primary purpose of a death inquest is to determine the cause and circumstances of deaths that occur in sudden, unexpected or unnatural circumstances. Notwithstanding this, a distinct and broader function — the prevention of death by public exposure of conditions that threaten life — has become increasingly significant.[3] This function is inextricably linked with the coroner’s ability to issue recommendations based on the circumstances of the death occurred, so that future deaths arising from similar circumstances can be prevented.[4]
However, it has been observed that the coroner courts in Malaysia have been reticent in providing recommendations to prevent similar fatalities.[5] Thus, it is this silence on coronial recommendations in Malaysia that this article seeks to delve into by analysing local and overseas experience in this aspect. This article will also analyse the recent change of coroners’ attitude in issuing recommendations in Malaysia and will end with proposals for the quest of this sought-after voice.
II. MALAYSIAN CORONIAL SYSTEM: AN OVERVIEW
A. Procedural Aspect of Death Inquest
Death inquest is governed by Chapter XXXII of the Criminal Procedure Code (CPC), and also Practice Direction 2/2019, which seeks to complement the procedure of death inquest in the CPC. In Malaysia, the Coroner’s Court has been established to conduct inquests, and the court must be presided over by a Sessions Court judge as the coroner.[6] An inquest is an official and public inquiry into the cause of a sudden, unnatural, unexplained or violent death. It is not usually held if a post-mortem examination of the body can explain the cause of death.[7] However, it is mandatory for the coroner to hold an inquest, if the Public Prosecutor directs the coroner to do so,[8] or if a person dies while in the custody of the police.[9]
There are certain instances in which the Practice Direction has prescribed that an inquest should usually be held:[10]
Any death where there is such uncertainty or conflict of evidence as to justify the use of the judicial forensic process.
Any death in which there is likelihood that an inquest will uncover important systemic defects or risks not already known about.
Any death in which the views of family or other significant members of the public are such that an Inquest is likely to assist maintaining public confidence in the administration of justice, health services or other public agencies.
Any death that when grouped with others that have occurred in similar circumstances indicates that there may be an unexpected increase of danger in a particular location, area, family, industry or activity.
Any workplace death in which industrial processes or activities are implicated.
Any disaster involving multiple deaths.
Any death from self-harm in which it is not possible to exclude the involvement of a third party in procuring the death or in failing to prevent it.
An inquest will be held in open court, unless the coroner, on special grounds of public policy or expediency, decides not to do so.[11] The coroner will have control of the proceedings, and thus it is the coroner that will examine the witnesses, to be followed by others who have the right to participate in the inquest, also known as ‘interested persons’.[12] The coroner will exercise his discretion to determine who shall have the right to examine the witness.[13] The coroner will also be assisted by a Deputy Public Prosecutor in an inquest.[14]
At the conclusion of an inquest, a decision will be made on how, when and where the death occurred. This is referred to as the inquest ‘verdict’. There is an exclusive list of verdicts that can be declared by the coroner, comprising of an open verdict, misadventure, natural death, homicide and suicide.[15] However, it must be noted that an inquest is only a fact-finding process, and not a fault-finding process. The verdict of a coroner is ‘only an expression of a nonbinding opinion of a proceeding where there is no accusation against any party’,[16] hence the verdict does not amount to a conviction.[17] The Practice Direction has specifically prohibited the coroner from framing his verdict to determine any question of criminal or civil liability on the part of a named person.[18]
Notably, there is no express provision either in the CPC or the Practice Direction that allows the coroner to make recommendations to prevent similar deaths from occurring.
B. Duty of Coroners
The duty of a coroner in Malaysia is succinctly stated in S.337 of the CPC:
‘A magistrate (coroner) holding an inquiry shall inquire when, where, how and after what manner the deceased came by his death and also whether any person is criminally concerned in the cause of the death.’
Practice Direction 2/2019 further requires the coroner to ascertain the identity of the deceased, if the deceased is one whose identity is not known.
A careful consideration of S.337 would reveal that the primary duty of a coroner is to establish the cause of death.[19] It must be noted that the words ‘cause of death’ are statutorily defined under S.328 of the CPC to include not only the apparent cause of death as ascertainable by inspection or post-mortem, but also all matters as to the manner in which the deceased came by his death and as to whether his death resulted from any unlawful act or omission.[20] Therefore, a coroner’s duty is not merely ascertaining the medical cause of death, but extends to establishing the circumstances of death, such as whether the cause of death may be unnatural or involve criminal elements.
III. OTHER JURISDICTIONS’ APPROACHES: UBIQUITY OF CORONIAL RECOMMENDATIONS
A perusal of other common law jurisdictions’ experience would indicate that the desirability of coroners making recommendations for remedial action to prevent similar deaths to the one under investigation commands universal acceptance.
In Singapore, S.27(2) of the Coroners Act implicitly allows coroners to issue recommendations when delivering their verdicts.[21] Notably, coroners in Singapore have been fearless and frank in giving recommendations to prevent similar fatalities. Examples of recommendations made by Singaporean coroners to prevent deaths include:
Singapore Civil Defence Force to strengthen support for mentally distressed recruits to reduce their suicidal tendencies.[22]
Review of protocols for post-surgery care — a doctor delivering primary care to a post-surgery patient must arrange for a stand-in if he is going to be unavailable.[23]
Singapore Botanic Garden to reinforce tree inspections for old and large trees to allow longitudinal tracing and visual examination over years, so that actual baseline health of the tree can be calculated to prevent trees from collapsing.[24]
In Hong Kong, S.44(2) of the Coroners Ordinance empowers a coroner to make a recommendation designed to (a) prevent the recurrence of similar fatalities, (b) prevent life hazards disclosed by the evidence or (c) bring to the attention of the relevant person deficiencies in a system or method of work which are disclosed by the evidence at the inquest and which are of public concern. The Hong Kong coroner courts also have been regularly issuing such recommendations in inquests, such as:
Marathon organisers to deploy more first-aiders and automated external defibrillators (AEDs), devices that can help with life-threatening cardiac arrhythmias, near the finishing line.[25]
Inmates detained in correctional facilities to work in pairs when cleaning areas in security camera blind spots to prevent self-harm.[26]
Police force to enhance crisis management training.[27]
Similarly, in common law jurisdictions such as the United Kingdom, Australia, New Zealand and Canada, it is very common for coroners to make recommendations in respect to ways of preventing further deaths.
IV. AN OUTLOOK OF MALAYSIAN EXPERIENCE
A. Seemingly Silent: All Quiet on Recommendations
Awkwardly, coroners in Malaysian do not favour providing recommendations when they deliver verdicts, and this raises a question as to whether they knowingly or unintentionally avoiding to do so.
The case of In Re Anthony Chang Kim Fook, Deceased[28] elucidates a little as to the coroners’ omission. In this case, Justice Sulong Matjaraie held that S.337 serves as the ‘terms of reference’ within which the coroner conducts the inquest into the death of the deceased. As such a coroner ‘cannot act outside the perimeter’ of S.337 of the CPC. This delineation of the exact province of a coroner’s power has received judicial affirmations from latter decisions, such as Inquest into the Death of Rumie bin Mahlie,[29] Ganga Gowri a/p Raja Sundram v Pendakwa Raya[30] and Chung Sui Keong (deceased).[31] Thus, it is believed that a coroner may be led to think that, he or she is strictly confined to inspect and discern the cause of death in his verdict, and should not do anything more than that, including providing recommendations.
A rare glimpse of the answer for this vexed question is offered in the inquest into the death of Sujatha Krishnan.[32] Coroner Mohd Faizi Che Abu, in delivering the verdict, noted that coroners in foreign jurisdictions have been giving recommendations, if they think it is necessary to prevent future fatalities. The learned coroner had identified several serious procedural defects committed by the health authority in the case, such as the disappearance of urine samples and the failure to perform a post-mortem. Nevertheless, he refused to provide comments nor recommendations, for that would ‘run foul’ of S.337[33] of the CPC.[34]
This case has shed light on why our coroners have been reserved in providing recommendations — they opine that their hands are tied due to the four corners delineated by S.337. However, it is submitted that, our CPC and Practice Direction are, more accurately, silent on the coroner’s power of giving recommendations, instead of being proscriptive towards it.
There is, therefore, a legal vacuum as to whether a coroner is allowed to give recommendations when delivering verdicts. Without express authorisation or signpost from the Parliament, it would be unlikely that our coroners would take a further step, lest be mauled for acting beyond the powers conferred upon them. It is hence submitted that the absence of an express provision authorising coroners to make recommendations is a major flaw in our criminal procedure law, and constructive opinions from the coroners for systemic changes to prevent death have been significantly disincentivised and hindered due to the said absence.
B. Moving towards a New Vantage Point?
Previously, coroners had rarely, if not never, spelt out their recommendations when they were concluding inquests. Similarly, comments were also rarely issued. It must be noted that there is a fine difference between a coronial ‘comment’ and a coronial ‘recommendation’. A ‘comment’ is a general observation that does not usually call for a response, whereas a ‘recommendation’ is addressed to a specific authority or organisation and it will usually call for change and/or response.[35]
Although there is a marked display of judicial restraint by our coroners in issuing both comment and recommendation, recently there has been a noticeable change of judicial attitude, where coroners have been seen to embark on issuing comments.
1. Inquest into the death of Ivana Smit
One clear example is the inquest into the death of Ivana Smit, a Dutch model who was found dead on the sixth floor of a Kuala Lumpur condominium in December 2017.[36] In 2019, the Coroner’s Court has ruled that the death of Ivana was due to misadventure, and that there was no foul play nor were there individuals involved in the case.[37] Subsequently, the High Court set aside the coroner’s verdict, and instead ruled that the death was caused by ‘persons known or unknown’.[38]
Notwithstanding that the verdict had been overturned, it is noteworthy that Coroner Mahyon Talib, had in her verdict, heavily criticised the investigating officer ‘for not doing the right thing’ and remarked that he ‘could have done a better job’.[39] Other vigorous remarks include:
‘He (the investigating officer) should also have checked the apartment for any alcoholic drinks and so on and passed this to the forensics department for analysis and DNA testing. This was not done.’[40]
‘It is a mystery and indeed a tragedy when ASP Faizal (the investigating officer) did not do the right thing (to further question witnesses who had made suspicious statements).’[41]
The learned coroner also hammered the pathologist who failed to visit the scene and inferred Ivana’s cause of death based on pictures of the scene provided by police.[42] Needless to say, these statements by Coroner Mahyon Talib are mere ‘comments’, and do not account for ‘recommendations’. However, if compared to the learned coroner in Sujatha Krishnan[43] who expressly refrained from providing comments nor recommendations, a small change in terms of judicial attitude can already be observed.
2. Inquest into the death of Muhammad Adib
Another rare occasion where a coroner stepped up and gave comments in Malaysia was the recent ‘Adib’s inquest’. Muhammad Adib, a firefighter, was severely injured when he arrived in the vicinity of the Seafield Sri Maha Mariamman Temple on 27 November 2018 to put out a car fire during riots, which purportedly arose over the relocation of a house of worship.[44] An inquest was called following conflicting accounts of the events leading to Muhammad Adib’s injuries, which include him being accidentally hit by his own emergency vehicle or being attacked by people who pulled him out of a vehicle.[45]
Eventually, the Coroner’s Court ruled that the death of Muhammad Adib was due to a criminal act committed by two or more unidentified persons.[46] Coroner Rofiah Mohamad further said that omission on the part of the authorities was a contributing factor to his death.[47] She ruled that the police and the Federal Reserve Unit[48]had failed to suppress the chaos of rioters attacking the firefighters.[49] Notably, strong comments were given by Coroner Rofiah Mohamad when she delivered her verdict:
‘[I]f they (police) had taken necessary actions, the fire would not have happened and the Fire and Rescue Department would not have come and Adib would not have died.’[50]
‘It is very unfortunate when two troops of FRU with hundreds of personnel and seven types of vehicles, including water cannons, only watched the rioters attack the firefighters without doing anything.’[51]
‘They (FRU) were only standing by with their weapons because they didn't receive any orders to act, despite the tense situation.’[52]
Such comments, although strictly speaking formed part of the cause and circumstance of death, and definitely fell short of a recommendation, have been very forceful and influential. In light of the inquest results, Inspector-General of Police Abdul Hamid Bador has said that the police will look into the case again and check if its standard operating procedure for riot control was adhered to during the Seafield riot.[53] There were also calls for the government to order an investigation into the police’s inaction.[54]
Clearly, comments and recommendations are able to generate considerable publicity and would serve as a warning bell to the relevant authorities to prevent similar fatalities. Therefore, it is hoped that more coroners in Malaysia could be more courageous to speak up and deliver recommendations when they are delivering their verdicts.
V. QUO VADIS, THEN?
In terms of the law on coronial recommendation, Malaysia is undoubtedly lagging behind. Coronial law on this aspect in many other jurisdictions (such as United Kingdom, New Zealand, Singapore and Hong Kong) have developed considerably, and after a perusal of their approaches, the author has made several proposals:
A. Prescribing the Preventive Function of Coroners
The legislation should formally and expressly recognise the preventative role of coroners as one of the purposes of death inquests. For instance, in S.3 of the New Zealand Coroners Act 2006, it is expressly stated that the purpose of the statute is to help to prevent deaths and to promote justice through (a) investigation and identification of the cause of death and (b) making recommendations or comments. If Chapter XXXII of the CPC — governing chapter for death inquest — could spell out such preventive function of coroners, it is believed that it will better cement the role of coroners and enhance the value of recommendations rather than merely enabling a coroner to make recommendations in relation to death.
B. Coroners must be Expressly Empowered to Make Recommendations
It is submitted that the current silence in our CPC is one major reason that deters coroners from issuing recommendations. Not to mention that acting beyond the scope of power granted is unacceptable under the rule of law. Thus, it is proposed that power must be expressly conferred upon our coroners to make recommendations.
Of course, concern would arise as to the proper parameters of coroners’ power, that the coroners are exceeding their statutory mandate if they divert their concentration to recommendations instead of the cause of death. Worse, there might be tensions between the judiciary and the other limbs of government, particularly the executive.
Therefore, the proposed amendment must clarify that coroners cannot embark upon free-ranging, unconstrained inquiries about whatever matters interest them and which may be tangential to the circumstances of a deceased person’s death.[55] It is also best to expressly limit recommendations to be made only for the purpose of reducing the chances of further deaths occurring in similar circumstances, and that the recommendations must be clearly linked to the factors that contributed to the death to which the inquiry relates and be based on evidence considered during the inquest.[56]
C. Responding Obligation towards Coronial Recommendations
First, to maximise the preventive potential of coronial recommendations, there must be an effective process to communicate findings to the relevant entities. This is to ensure that the relevant entities are sufficiently informed of the issues canvassed at the inquest, and the recommendations made by the coroners, to enable them to take appropriate measures.
Some suggest that entities who fail to comply with coronial recommendations would expose themselves to the very real risk of severe public criticism as a result, and this would serve as an adequate deterrent to those who might choose not to act upon such a recommendation.[57] However, it is observed that the most prevalent concern in most jurisdictions where coronial recommendations are commonly issued, voiced in a succession of public inquiries, is that the recommendations are ineffective because the entities to which they are directed to, ignore them.[58]
Thus, legal obligations are commonly imposed in various jurisdictions to compel entities to respond to recommendations addressed to them within a specified time. Such response enhances accountability, particularly in the eyes of the grieving families, who rightfully expect that any systemic changes recommended by the coroner to avoid further deaths in similar circumstances should be implemented by the relevant public sector agency.[59]Therefore, it is submitted that an organisation that receives a recommendation from a coroner must respond in writing within a reasonable period of time, outlining any action it has, is or will be taking in response.[60]
VI. CLOSING REMARK
‘Every single death represents the tip of the iceberg of injuries and other high-risk circumstances.’[61]
The current legal loophole has prevented Malaysia to harness the potential of coronial recommendations. Thus, the Parliament should formally recognise the social utility in convening a coroner’s inquest not only to make findings about circumstances and causes of death, but to make recommendations directed towards avoidance in the future of avoidable deaths. It is time to expressly acknowledge coronial recommendation in our criminal procedure regime.
In fact, there are numerous shortcomings in our death inquest system, which require empirical studies and structural reforms. Particularly, a chorus of calls has been heard for some time, advocating for a stand-alone legislation to govern the coronial processes.[62] Unfortunately, with coronial law suffering an acute lack of interest, Malaysia has a long way to go, not only in encouraging coronial recommendation, but also in revising the coronial system as a whole.
Disclaimer: The opinions expressed in this article are those of the author and do not necessarily reflect the views of the University of Malaya Law Review, and the institution it is affiliated with.
Footnotes:
[1] Olayinka Oyegbile, “On Justice Oluwa”, The Nation, 17 May 2020, 24 May 2020 <https://thenationonlineng.net/on-justice-oluwa/>.
[2] It must be noted that in our Criminal Procedure Code (Act 593), “inquest” is referred to as “inquiry of death”.
[3] People First of Ontario v Porter (1991) 5 OR (3d) 609, at [33].
[4] Mok, E, “Harnessing the Full Potential of Coroners' Recommendations”, (2014) 45 Victoria University of Wellington Law Review, 321–366.
[5] Ismail, N, “Application of International Convention on Human Rights in British Coronial System as an Example for Malaysia”, (2010) 14 Jurnal Undang-Undang 35–53, at 48.
[6] Chief Justice Federal Court Malaysia, Practice Direction No. 2 of 2019 – Pengendalian Laporan Mati Mengejut Dan Siasatan Kematian Oleh Mahkamah Sesyen Koroner, 8 March 2019 (“Practice Direction 2/2019”), at [2].
[7] Criminal Procedure Code (Act 593), S.333.
[8] Criminal Procedure Code (Act 593), S.339.
[9] Criminal Procedure Code (Act 593), S.334.
[10] Practice Direction 2/2019, at Appendix A [3D].
[11] Criminal Procedure Code (Act 593), S.338(2).
[12] Practice Direction 2/2019, at Appendix A [5A].
[13] See footnote 12.
[14] See footnote 12.
[15] Practice Direction 2/2019, at Appendix A [5H].
[16] Re Rumie Mahlie, Deceased [2007] 10 CLJ 697 (HC).
[17] Teoh Meng Kee v PP [2014] 7 CLJ 1034, at [48].
[18] Practice Direction 2/2019, at Appendix A [5H].
[19] Criminal Procedure Code (Act 593), S.337.
[20] Criminal Procedure Code (Act 593), S.328.
[21] Coroners Act (Singapore), S.27(2).
[22] Lydia Lam, “SCDF reviewed processes after NSF's suicide; coroner recommends appointing mental health experts”, Channel News Asia, 20 November 2019, 25 April. 2020 <https://www.channelnewsasia.com/news/singapore/scdf-reviewed-processes-after-nsf-s-suicide-coroner-recommends-12110040>.
[23] Channel News Asia, “Woman died in hospital from multi-organ failure after knee replacement surgery”, Channel News Asia, 17 September 2019, 23 May 2020 <https://www.channelnewsasia.com/news/singapore/woman-died-mount-elizabeth-hospital-dr-sean-ng-knee-surgery-11912566>.
[24] Jalelah Abu Baker, “Tembusu tree accident: Death of woman a 'tragic misadventure', says coroner”, Channel News Asia, 30 April 2018, 25 April 2020 <https://www.channelnewsasia.com/news/singapore/tembusu-tree-accident-death-of-woman-a-tragic-misadventure-says-10188628>.
[25] See footnote 24.
[26] Jasmine Siu, “Inmates must work in pairs when cleaning areas in security camera blind spots, Hong Kong Coroner’s Court rules, after man facing rape charge hanged himself”, South China Morning Post, 22 May 2019, 25 April 2020 <https://www.scmp.com/news/hong-kong/law-and-crime/article/3011368/inmates-must-work-pairs-when-cleaning-areas-security>.
[27] Chris Lau, “Police legally shot dead Hong Kong man who rushed towards wife with paper cutter, jury says”, South China Morning Post, 8 December 2017, 24 May 2020 <https://www.scmp.com/news/hong-kong/law-crime/article/2123503/police-legally-shot-dead-hong-kong-man-who-rushed-towards>.
[28] In Re Anthony Chang Kim Fook, Deceased [2007] 2 CLJ 362.
[29] Inquest into the Death of Rumie bin Mahlie [2007] MLJU 280.
[30] Ganga Gowri a/p Raja Sundram v Pendakwa Raya [2012] 9 MLJ 733; [2012] MLJU 634; [2012] 7 CLJ 180.
[31] Chung Sui Keong (deceased) [2010] MLJU 107.
[32] In Re Inquest Into The Death Of Sujatha Krishnan, Deceased [2009] 5 CLJ 783.
[33] S.337 provides that a coroner should inquire when, where, how and after what manner the deceased came by his death and also whether any person is criminally concerned in the cause of the death in an inquest.
[34] The Coroner had, in fact, ruled that it would run afoul of “S.339”. However, it is submitted that the Coroner has cited the incorrect provision, as S.339 relates to the power of Public Prosecutor to require an inquest to be held. He most likely intended to cite ‘S.337’ which relates to the duty of a coroner in an inquest.
[35] Jennifer Moore, Coroners' Recommendations and the Promise of Saved Lives, (New Zealand: Edward Elgar Publishing, 2016) at 68.
[36] Nurbaiti Hamdan, “Coroner's Court rules Dutch model's death due to misadventure”, The Star, 8 March 2019, 24 April 2020 <https://www.thestar.com.my/news/nation/2019/03/08/coroners-court-rules-dutch-models-death-due-to-misadventure>.
[37] See footnote 36.
[38] Bernama, “High Court set aside coroner’s decision that Ivana Smit’s death due to misadventure”, The Sun Daily, 22 November 2019, 24 April 2020 <https://www.thesundaily.my/local/high-court-set-aside-coroner-s-decision-that-ivana-smit-s-death-due-to-misadventure-XA1640505>.
[39] Vinodh Pillai, “Coroner raps IO in Ivana case for ‘not doing the right thing’”, Free Malaysia Today, 8 March 2019, 24 April 2020 <https://www.freemalaysiatoday.com/category/nation/2019/03/08/coroner-raps-io-in-ivana-case-for-not-doing-the-right-thing/>.
[40] See footnote 39.
[41] “Judge questions officer’s conduct in probing model’s death”, The Star, 9 March 2019, 24 April 2020 <https://www.thestar.com.my/news/nation/2019/03/09/judge-questions-officers-conduct-in-probing-models-death>.
[42] “IO, pathologist in Dutch model's case ticked off by coroner, told they could have done a better job”, New Straits Times, 8 March 2019, 24 April 2020 <https://www.nst.com.my/news/crime-courts/2019/03/467371/io-pathologist-dutch-models-case-ticked-coroner-told-they-could>.
[43] In Re Inquest Into The Death Of Sujatha Krishnan, Deceased [2009] 5 CLJ 783.
[44] Bernama, “Temple task force, devotees fail to be interested parties in Adib's inquest”, New Straits Times, 31 January 2019, 24 April 2020 <https://www.nst.com.my/news/crime-courts/2019/01/456207/temple-task-force-devotees-fail-be-interested-parties-adibs-inquest>.
[45] Yiswaree Palansamy, “Inquest sees crime in fireman Adib’s death”, Malay Mail, 27 September 2019, 24 April 2020 <https://www.malaymail.com/news/malaysia/2019/09/27/inquest-concludes-foul-play-in-fireman-adibs-death/1794768>.
[46] Bernama, “Foul play involved in Adib’s death”, The Star Online, 28 September 2019, 24 April 2020 <https://www.thestar.com.my/news/nation/2019/09/28/foul-play-involved-in-adibs-death>.
[47] Yiswaree Palansamy, “Inquest sees crime in fireman Adib’s death”, Malay Mail, 27 September 2019, 24 April 2020 <https://www.malaymail.com/news/malaysia/2019/09/27/inquest-concludes-foul-play-in-fireman-adibs-death/1794768>.
[48] More commonly known as “FRU”, or “Pasukan Simpanan Persekutuan”, Federal Reserve Unit is a riot control force and a paramilitary special response team that can be deployed at any time to engage in any emergency or public unrest in Malaysia.
[49] Hariz Mohd, “Coroner: If cops had acted, there would be no fires nor firefighters, Malaysiakini, 27 September 2019, 24 April 2020 <https://www.malaysiakini.com/news/493539>.
[50] Charles Ramendran and Kevin Davasagayam, “Coroner’s Court rules that murder was the cause of Muhammad Adib’s death”, The Sun Daily, 27 September 2019, 24 April 2020 <https://www.thesundaily.my/local/coroner-s-court-rules-that-murder-was-the-cause-of-muhammad-adib-s-death-updated-NA1424359>.
[51] Hariz Mohd, “Coroner: If cops had acted, there would be no fires nor firefighters, Malaysiakini, 27 September 2019, 24 April 2020 <https://www.malaysiakini.com/news/493539>.
[52] See footnote 51.
[53] Hazlin Hassan, “Death of Malaysian fireman injured during rioting at Hindu temple caused by unknown persons”, Straits Times, 27 September 2019, 24 April 2020 <https://www.straitstimes.com/asia/se-asia/death-of-malaysian-fireman-injured-during-selangor-hindu-temple-riot-caused-by-persons>.
[54] Malaysiakini, “After coroner's damning verdict, Zaid wants gov't to probe police's inaction”, Malaysiakini, 27 September 2019, 24 April 2020 <https://www.malaysiakini.com/news/493505>.
[55] Freckelton, I. (2007). Death investigation, the coroner and therapeutic jurisprudence. Journal of Law and Medicine, 15, 1–12.
[56] See, eg, S.3 of the Coroners Act 2006 (New Zealand).
[57] The Law Reform Commission of Hong Kong, Report on Coroners, (1987), <https://www.hkreform.gov.hk/en/docs/rcoroners-e.pdf>.
[58] Sutherland, Georgina, et al., “What happens to coroners’ recommendations for improving public health and safety? Organisational responses under a mandatory response regime in Victoria, Australia”, (2014) 14 BMC Public Health 732.
[59] Queensland Ombudsman, The Coronial Recommendations Project: An investigation into the administrative practice of Queensland public sector agencies in assisting coronial inquiries and responding to coronial recommendations, December 2006 <https://www.ombudsman.qld.gov.au/ArticleDocuments/307/Coronial%20Recommendations%20Project%20Report.pdf.aspx?Embed=Y>.
[60] See, eg, S.72(3) and (4) of the Coroners Act 2008 (Victoria, Australia).
[61] Queensland Ombudsman, op. cit., at 7.
[62] Koshy, S, “Malaysian Bar chief: Time for coroner to direct investigations”, The Star, 29 July 2012, 24 May 2020, <https://www.thestar.com.my/news/nation/2012/07/29/malaysian-bar-chief-time-for-coroner-to-direct-investigations>.