Current coronial inquiries in Australia hold an important role in learning from the loss of someone we love. However, these processes can fail to prevent future deaths because they, along with the public mental health system more broadly, have not “learnt how to learn” from catastrophic failure. These failures stem from two critical and connected gaps: the marginalisation—and structural exclusion—of lived experience expertise from coronial processes, and the absence of a human rights‑based lens. A recent well-established and resourced NSW coronial process failed to interview a single consumer lived experience expert.

Without engaging with the personal and collective knowledge of families, suicide attempt survivors, and consumer lived experience voices—who are largely positioned outside formal coronial inquiry structures—and the peak bodies that bring this expertise together, inquiries miss the nuances of why systems fail people in distress. This structural absence limits the capacity of coronial processes to surface patterns of harm, power imbalance, and preventable risk. Furthermore, without a human rights framework, inquiries tend to focus on whether a policy was followed, rather than situating deaths within the complex relationships between people, policies, systems and history in a way that centres safety, dignity and accountability.

This symposium will bring together a coronial expert, a bereaved family member, a suicide attempt survivor, a psychiatrist, and a consumer peak body to ask: how can we learn to learn better from loss and harm? We will explore the role of coronial processes in this learning, how they might shift culture and practice, and how lived experience expertise can be meaningfully embedded earlier. We will also examine the systemic and structural failures that result in coronial inquiries becoming the last train stop for learning, and what earlier processes and systems are required to prevent harm before life is lost.