The coronial system

July 22nd, 2014 at 4:00 pm by David Farrar

Stuff reports:

Serious failings and under-resourcing in the coronial system are stopping coroners from preventing further deaths, research has found.

Some coroners feel their recommendations have been falling on deaf ears, according to an Otago University study that looked at more than 600 coroners’ reports.

That’s because so many of their recommendations are daft and impractical.

The failings were evident in the high number of repeated recommendations, particularly in cases of drowning, sudden unexplained infant deaths, and transport accidents.

Research author Jennifer Moore said she wanted the law changed to make the system more effective, but it was unlikely the Government would budge.

About 72 recommendations were vaguely directed, and she believed there should be a mandatory response system in place.

The non silly ones do tend to get a response, but the problem is too many coroners come up with recommendations that are unbalanced. Their aim is to recommend ways to reduce deaths, which is of course a good thing. But some never seem to consider practicality or compliance costs, let alone freedom of choice to do stupid things.

There should also be additional support, training and resources available for coroners, she said.

Coroners did not receive training from a judicial institute, which she said would improve the quality of recommendations. The 17 coroners did not have books with decades of full decisions to refer to, and had to share two assistants.

Now that I would support.

Chief Neil MacLean said the research was a valuable, objective point of view. “We’re already taking on board some of the criticism and I hope the Government will listen to their recommendations.”

Under-resourcing was a particular day-to-day frustration, he said. One of the most effective changes would be making it mandatory for agencies to respond to recommendations directed at them. “The thing about having a rigorous, transparent, mandatory response system is that we can be assured of feedback. We accept that some of the recommendations we make are unbalanced or miscued or directed at the wrong people – we need to know that, so we can do better next time.”

That’s a fair point. The Chief Coroner is, in my opinion, excellent. What I’d rather do is institute better resourcing and training, and then after that review if mandatory responses are a good idea.

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12 Responses to “The coronial system”

  1. tvb (4,422 comments) says:

    A coroner’s main function is to establish the facts of what caused a death. They are not so well placed to start making recommendations to public policy. They can but they are not well placed to do it. Many regulations have an economic impact and I am yet to see a Judicial Officer having any idea about economic analysis.

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  2. JMS (330 comments) says:

    What I’d rather do is institute better resourcing and training

    No, no, not more resourcing, training yes, but not resourcing.

    That’s what all bureaucracies want.

    Spend their days being lazy or empire building.

    Then when something goes wrong, ask for more funding.

    Civil Aviation Authority is the most glaring example of this, but there are plenty of others too.

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  3. nasska (11,510 comments) says:

    Coroners seem to come from the ranks of lawyers & are seldom the most pragmatic of people. In most cases they wring their hands at the humanity of it all & make half baked suggestions with scant regard to existing practise, cost or implications.

    Recommendations they can make if it keeps them happy & off the streets but for God’s sake don’t give the idiots any real power!

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  4. shoreboy57 (140 comments) says:

    For anyone who needs reminding of why coroner’s recommendations should not be binding, here is a comprehensive list from Eric Crampton. Feel free to add to it

    http://offsettingbehaviour.blogspot.co.nz/2013/02/coroner-recommends.html

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  5. burt (8,271 comments) says:

    What’s been bugging Jim Anderton recently -that’s always been a great indicator for what the Coroners can and cannot say !

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  6. JC (956 comments) says:

    No more money or staff. Simply find the cause of death and put it in an easy to access public register under similar circumstances and causes so anyone can check.

    The media could do a valuable job of checking it and publishing trends as well as the million busybodies in our society.

    JC

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  7. Michael (909 comments) says:

    Coronal recommendations should only be required where another person or organisation significantly contributed to the death, and where there has been no criminal culpability established. Otherwise the coroners will keep making recommendations to prevent the same deaths again.

    Richard Prebble (then the Minister of Transport) had the right attitude after the Mikhail Lermontov sinking – he judged it was a one-off, exceptional set of circumstances and that the event itself would act as a deterent to other shipping to not rely on local pilots and be prepared to check and challenge instructions. So he didn’t initiate an inquiry that would have recommended other steps to prevent another occurrence. And in the 30 years since the sinking, there has not been another large cruise ship lost in New Zealand waters without such an inquiry or set of recommendations.

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  8. anonymouse (716 comments) says:

    There should also be additional support, training and resources available for coroners, she said.
    The 17 coroners did not have books with decades of full decisions to refer to, and had to share two assistants

    Additional resources, hmm let me take a look at some of the resources provided to Coroners,

    Coroners (Salaries and Superannuation) Determination 2014
    5 Salaries of coroners
    (1) The salary payable to a coroner must be at the annual rate of $249,500.

    So how about you all chip in $10K and fund a few more assistants,

    You are already paid very well from the public purse, now how about you stop winging and DO YOUR JOB…

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  9. peterwn (3,273 comments) says:

    And some years ago, when a coroner was systematically studying childbirth deaths and was making headway, the Feminazti went screaming off to Helen and her ministers to deal with him.

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  10. trout (939 comments) says:

    Coroners do not, by and large, take account of the ‘stupidity quotient’ in their findings. For example we could spend millions on water safety, make life jackets compulsory, create inconvenience for the majority of sailors, and yet will not not save some people from the consequences of their own stupidity. Some people will find a way to injure or kill themselves regardless. Coroners are at risk of becoming drivers of the ‘nanny state’.

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  11. peterwn (3,273 comments) says:

    trout – coroners cannot call the deceased ‘stupid’ or like words. A former Auckland coroner frequently did, rellies got upset and lobbied successfully for a law change. Rellies and others who want to take issue with what a coroner said can go to the High Court and a few have.

    tvb – Judge Learned Hand (no kidding as to name!) in USA considered economic factors in the United States v Carroll Towing Co (a marine case), although I agree that judges, etc do not like to try and quantify things.

    For example, murder includes intending to inflict injuries such that death is ‘likely’. No judge AFAIK has tried to quantify ‘likely’ and just leave it to the jury with general guidelines.

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  12. backster (2,172 comments) says:

    “(1) The salary payable to a coroner must be at the annual rate of $249,500.

    So how about you all chip in $10K and fund a few more assistants,

    You are already paid very well from the public purse, now how about you stop winging and DO YOUR JOB…

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    I fail to see any improvement since coronial functions were a part time job carried out largely by a retired lawyer.

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