Corrective Services NSW


Terms of reference

1 Purpose

1.1 The Aboriginal Deaths in CSNSW Custody Thematic Review is established to examine the circumstances and the findings from investigations into deaths of Aboriginal people that have occurred while in the custody of Corrective Services NSW (CSNSW) over the period 2010 to present. The Thematic review will generate a report to the Minister of Corrections synthesising findings and developing key recommendations for action that aim to improve the experience of Aboriginal men and women in custody and reduce the loss of life. Themes and lessons will also be generated where relevant from the deaths of non-Aboriginal offenders.

1.2 The thematic review will have regard to previous reports/reviews into Aboriginal Deaths in Custody in NSW, including the Royal Commission into Aboriginal Deaths in Custody and the Select Committee of Inquiry into Overrepresentation of First Nations in custody and Oversight of Deaths in Custody. This thematic review was initiated by the Minister for Corrections and is being led from within CSNSW and significantly has support and engagement from key stakeholders including Justice Health & Forensic Mental Health (JH&FMHN) Network, relevant academics, Aboriginal representatives and will seek input from Aboriginal families, community groups and advocates.  

1.3 The review is a thematic review and narrowly framed. It is not intended to address the highly relevant issues of over-representation of Aboriginal persons in custody or to re-investigate deaths or ascribe blame to individuals or review coronial processes (with the exception of CSNSW involvement).

2 Objects of Review

2.1 The thematic review will:

  1. Analyse recurring or emerging themes arising from coronial findings, CSNSW and JH&FMHN investigations into Aboriginal deaths in custody during the relevant period.  
  2. a. Information sources for review/text mining will include:

    i. CSNSW data and records including investigation reports and incident reports, OIMS

    ii. Coronial Findings and recommendations

    iii. JH&FMHN critical incident reviews and recommendations.

  3. Undertake statistical analysis of demographic and risk factors to confirm apparent patterns that may be relevant to improve the risk assessment and management processes.
  4. Analyse and identify where good practice and protective elements impacted positively on the survival of prisoners at ‘high risk’ of death from natural or unnatural causes
  5. Capture the lived experience and examine collateral impacts of Aboriginal deaths in custody on staff, families and inmates that may be exacerbated by the investigation processes and unmet need for information and support following a death. 
  6. Engage in consultation with key Aboriginal Community Groups and advocates to provide opportunities for them to have input into the strategies that may be adopted to prevent deaths in custody.
  7. Review and progress relevant outstanding recommendations applicable to CSNSW from the Royal Commission into Aboriginal Deaths in Custody.
  8. Explore and prioritise technological and built environment projects that may contribute to prevention of deaths in custody

2.2 The comprehensive report to the Minister on the thematic review will be completed by mid 2024.

3 Review Structure

3.1 The project lead for the thematic review will be CSNSW Deputy Commissioner Luke Grant. 

3.2 The review will be guided by an expert reference group comprising external experts, CSNSW executive staff and JH&FMH representatives. The reference group will be chaired by an independent Aboriginal person – Professor James Ward.

3.3 Key data analyses will be undertaken through a combination of work commissioned from Dr Lyndal Bugeja - Associate Professor Monash University and work undertaken by the Corrections Research Evaluation and Statistics Group.

3.4 A project team from CSNSW and the JH&FMHN and assisted by former Deputy State Coroner Hugh Dillon will steer the project.

4 Membership

4.1 The Expert Reference Group will be chaired by an Aboriginal person independent of CSNSW and JH&FMHN – Professor James Ward. 

4.2 The Expert Reference Group consists of internal and external representatives with expertise relevant to the review.

External Participants:

  • Professor James Ward – Director Poche Centre UQ 
  • Dr Robyn Shields AM - Psychiatry Registrar NSW Health 
  • Ms Lil Gordon - Head of NSW Aboriginal Affairs 
  • Dr Lyndal Bugeja - Associate Professor Monash University
  • Mr Hugh Dillon – Former Deputy State Coroner and now adjunct Professor at the UNSW Law School 
  • Mr David Evenden, Solicitor Advocate Legal Aid NSW
  • Uncle Richie Lawton, Aboriginal Community Member
  •  Sandra Bailey, Aboriginal Community Member

Please see Expert Reference Group Profiles for External Members for further details about the External Participants. There are also senior Internal Participants, from CSNSW and JH&FMHN. 

Last updated:

06 Mar 2023

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We acknowledge Aboriginal people as the First Nations Peoples of NSW and pay our respects to Elders past, present and future. We acknowledge the ongoing connection Aboriginal people have to this land and recognise Aboriginal people as the original custodians of this land.

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