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 coroner 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.

Coroner misses the point

March 1st, 2014 at 10:00 am by David Farrar

Stuff reports:

A coroner is calling for better regulations of headlights following the death of a drunk man who was run over lying on a rural Hamilton road at night.

Hastings man William Gregory Hoskins was killed on January 15, 2012, after he was struck by a car on Marychurch Road in the early hours of the morning.

It is not known how he came to be lying on the road, Coroner Gary Evans said in findings released today.

Hoskins had travelled to Hamilton with family to attend a cousin’s wedding, and had been drinking at the reception.

A test found he had alcohol in his blood at a level of 190 milligrams per 100 milliletres, over twice the legal blood alcohol limit for drivers.

He had also smoked the equivalent of a single cannabis cigarette in the hours before his death, which may have accentuated the effects of alcohol, a report said. …


– Consideration be given to the creation of more detailed regulations as to the requirements of vehicle headlights.

– Consideration be given to revision of the warrant of fitness testing scheme with a view to measurement of the lux output of headlights and the distance at which they are operating efficiently.

– Greater emphasis be placed on the dangers of driving on dipped headlights on roads.

– Renewed consideration be given to the question of whether the Land Transport (Road User) Rules 2004 should contain a requirement or guide to the circumstances in which drivers must or should drive with their headlights on full beam.

I’ve got a simpler recommendation.

Don’t get so drunk and stoned that you fall asleep or unconscious on an unlit (or lit) road.

How about don’t drive quad bikes stoned?

November 11th, 2013 at 3:00 pm by David Farrar

Stuff reports:

Banning the use of quad bikes in farming has been raised as a prospect by a coroner in his written findings into five deaths related to their use.

Coroner Brandt Shortland stopped short of including a ban among his recommendations, saying the quad bike was entrenched as a vital farm tool.

Any speculating on such stuff is pretty silly.

Mendoza died after spending at least two days trapped beneath his quad bike when it overturned during weed spraying in September 2010.

He had been smoking cannabis between 30 minutes to five hours before his death.

McInnes was spraying a hilly slope for weeds when his quad bike rolled and crushed him to death in September 2010.

Ferguson died when trapped between her quad bike and an electric fence after trying to tow a trailer of silage up a hill in August 2010.

Cornelius was weed spraying when he was found dead, pinned under his quad bike in September 2011.

He had cannabis in his system consistent with smoking a single cannabis cigarette within three hours of his death.

Van Der Pasch died of a terminal head injury when his quad bike rolled onto his head in September 2011.

So two of the five deaths involved a driving who was stoned while driving the quad bike. I think the lesson is that quad bikes are not dangerous – drivers are.

Not convinced

March 6th, 2013 at 10:00 am by David Farrar

The Press editorial:

The decision of a coroner not to hold an inquest into the suicide of a New Zealand soldier in Afghanistan is beginning to look unfortunate.

While it is not unusual for coroners to decide not to conduct inquests into deaths that have already been subject to a well-run and thorough investigation, this decision appears not to satisfy members of the dead man’s family that the circumstances of their relative’s death have been adequately dealt with. A coroner, having decided not to hold an inquest, is entitled to change his or her mind.

The solicitor-general, as the chief executive of the department in charge of coroners, may also overrule the coroner’s decision. One or other of them should do so and a proper independent coroner’s inquiry should be held.

I’m not convinced that the coroner has made the wrong call. As the editorial says, it is unusual to have a coronial inquest when some other body has done an investigation. The fact some family members are upset is not a reason in itself. An inquest shouldn’t be seen as some sort of appeal board.

The causes of suicide are complex and it is seldom that any one factor drives a person to it. A long and detailed investigation into the soldier’s death has been conducted by a military court of inquiry. It has reported on the immediate circumstances of the death, which involved an emotional relationship contrary to military discipline.

The soldier’s family is dissatisfied, however, claiming that questions about the wider circumstances, including allegations of continual bullying and harassment of the soldier because of his homosexuality, have not been properly answered.

It is incredibly sad that the solider killed himself, and that somehow this outcome wasn’t avoided.

However from what I have seen the major issue wasn’t the fact that he was homosexual. It was that he had an unrequited attraction to another solider and told him about it – which obviously made things difficult. The original story said:

Later in the evening, Sergeant H, who family say Hughes did not get along with, confronted Hughes about the incident where he had embarrassed Trooper A.

According to the report, Hughes broke down, admitted he was gay, and had feelings for Trooper A.

Sergeant H organised a meeting between himself, Hughes, and Trooper A, where Hughes admitted to Trooper A he had concocted the incident with the female chef and reiterated his feelings for the trooper.

This is an issue which isn’t intrinsically tied to sexuality. If the attraction was to a female solider, it would also be problematic.

Few of us can control whom we are attracted to. I certainly can’t. But you can control whether or not you act on it, or tell people about it. In a number of former jobs I’ve had colleagues I was attracted to but would never have told them that as it would have caused problems in the workplace.

This is not to say the fact Hughes was gay and the attraction was to another male didn’t make the situation more stressful. I’m sure it did, and it is of huge regret that he ended up taking his life.

The report into Hughes’ death, prepared by an inquiry team that travelled to Afghanistan and interviewed 47 witnesses, does not record any instances of Hughes being bullied, mocked or humiliated, but his family suspect that was the case.

I think you need something more than suspicion, to claim the Army inquiry was inadequate. There is no proof at all that it was.

Now the issue is slightly muddied by the fact the coroner who declined to do an inquest wrote a submission to Parliament against the same sex marriage bill. There is a seperate debate you can have about the wisdom of a quasi-judicial officer doing that. But I don’t think that means he has necessarily made the wrong decision in not holding an inquest. Unless there is some proof that the Army inquiry was inadequate or missed vital evidence, I think the decision is the right one.

Bob Jones on coroners

February 20th, 2013 at 3:00 pm by David Farrar

Bob Jones writes in the NZ Herald regard the Coroner saying coke should have warning labels:

We read this sort of coroner guff frequently following unusual deaths in which, not content to simply do their job and officially state the cause of death, they instead ignore the extreme oddity of the circumstances and ascribe them to the community at large.

A circus elephant escapes, runs amok and tramples someone to death and the coroner will urge that the government makes us all build elephant-proof fences. A 158kg woman rolls over in bed in a drunken stupor and crushes to death her ex-jockey husband. This actually happened in Tasmania in the late 1980s.

Coroner Crear presumably would urge the government to ban jockeys and other small males sleeping with fat women, or alternatively, that fat women have a warning sign tattooed on their buttocks. In short, coroners too often fail to recognise freak accidents as simply that, namely freak.

Heh, so true.

Older readers will remember George Wilder who delighted us all with his prison escapes. Who can forget his escape from a Taranaki prison when the army was called in from Waiouru to assist prison officers and police searching for him on the central plateau where he had been spotted. Because they occasionally ran across hikers, at day’s end the searchers were shown a photo of George. “That bugger was here all day in the search party”, they all shouted, but too late, George had slipped off into the night.

George wasn’t publicly perceived as a villain, rather he was viewed as an addiction victim for his obsession with taking cars, riding about in them for half an hour then leaving them unharmed. He simply couldn’t stop himself despite endless court warnings. Coroner Crear would doubtless blame the car manufacturers and Professor Sellman would want cars added to the addictive substances list.

Highly likely! They always blame the company.

A good Coroner’s recommendation

February 20th, 2013 at 9:00 am by David Farrar

Stuff reports:

Transport Minister Gerry Brownlee has backed a coroner’s call to make prisoners serve their driving bans after they are freed, not while they are still in jail.

Coroner Garry Evans’ recommendation is contained in his report into the death of a young woman in a car crash caused by a paroled criminal who was on a witness protection programme at the time.

Debbie Ashton, 20, died when repeat driving offender Jonathan Barclay, a former P addict, smashed into her car while speeding and drunk, near Nelson in December 2006.

Barclay has twice served out driving bans while in prison for more serious offending. Both times he has gone on to crash into other people.

Seems like a no brainer to me.

In a statement last night, Mr Brownlee said he had asked officials from the justice and transport ministries to look into the recommendation. Any change would require an amendment to legislation, which meant it would have to be put before Parliament.

Will the Greens oppose it as they could argue it punishes the criminal twice?

Coroner recommendations

February 18th, 2013 at 3:00 pm by David Farrar

Eric Crampton blogs a list of recent Coronial recommendations, including:

The problem we have is Coroners only look at how to reduce deaths. They seem to often miss any requirement for balance such as whether their recommendations are practical or affordable – or if they may have undesirable consequences.

Lucy at Cycling Auckland takes issue with the last recommendation:

The Coroner made two recommendations, both of which I feel quite strongly would not help to improve cycling safety. Irritatingly, neither of them seem very relevant to the actual accident he investigated.

First, as mentioned in the media, he recommended that the wearing of hi viz should be made mandatory for all cyclists because he saw it as a “no-brainer.” He doesn’t present any evidence to support this view.

This recommendation seems oddly unrelated to the case, given that the crash happened at 5.20 pm when it was just getting dark and Stephen Fitzgerald was wearing both reflective hi viz stripes and functioning lights.

So it is not even relevant to this case – but the Coroner just thought it was a good idea. It isn’t.

The problem with both of these recommendations, in my opinion, is that while they would probably make individual cyclists safer if they followed them (although it’s arguable in the case of hi viz, because there is some evidence that drivers give cyclists more space when they look less experienced) overall they make cycling less attractive.

This is particularly true of the hi viz recommendation. Even riders such as myself, who have very little interest in fashion, would probably be put off by a permanent requirement to wear hi viz.

Because I don’t particularly want to walk around the supermarket or go to work in hi viz, such a law would require me to permanently wear a hi viz vest over my normal clothes. This would not only be hot in summer but also would be annoying to carry around when I reached my destination.

Obviously, of course, riders who actually care about how they look while riding – such as teenage girls or the Frocks on Bikes types – would quite likely choose not to ride at all if hi viz was mandatory.

I’ve yet to see a single person support the Coroner’s recommendation.

Another daft Coroner recommendation

February 15th, 2013 at 11:00 am by David Farrar

Stuff reports:

A Coroner is calling for high-visibility clothing to be compulsory for cyclists after a top road safety cop was struck while cycling in Petone.

Superintendent Steve Fitzgerald – who served for five years as New Zealand’s top traffic officer – was killed in the Lower Hutt suburb while cycling home from work in Wellington to Eastbourne on June 19, 2008.

The truck driver who hit him, Desmond Wilson, was found guilty of careless driving causing death, ordered to pay $2000 reparations, and disqualified for nine months. 

Now, Wellington Regional Coroner Ian Smith is calling for high-visibility clothing to be as compulsory as helmets for cyclists, enhanced cyclist education, a one-metre gap between motorist and cyclist be added to the road code, and clear rules about when a cyclist must use designated lanes only. …

‘Turning to the issue of hi-vis clothing it is in my view a no-brainer. It should be complulsory for cyclists to wear at all times when riding in public.”


First of all, if you are cycling at night you are a special sort of moron if you do not wear hi-vis gear.

But do we want a country where it is illegal to ever ride a bike if you don’t have hi-vis clothing?

Even on a country lane on a bright sunny day?

And don’t even think about how many Police hours would be spent on checking if a cyclist has their hi-vis clothing on.

I recall the report about how the lack of a helmet law in the Netherlands has led to vastly more people cycling there, and overall health gains.

Imagine how many people would be put off cycling with such a daft law?

The suggestions on the one meter gap and the rules about using designated lanes seem worthwhile though.

Coronial powers

August 6th, 2012 at 10:00 am by David Farrar

Stuff reports:

Giving coroners’ recommendations “more teeth” is a necessary change, the chief coroner says.

A review of the coronial system and the 2006 Coroners Act was announced yesterday by Courts Minister Chester Borrows.

It will be led by the Justice Ministry and will consider the role coroners have in making recommendations, as well as whether agencies should be required to formally respond to those recommendations. …

Chief coroner Judge Neil MacLean said it was important that agencies responded to coroners’ recommendations, whether it was to agree, disagree or state there was no money to make the changes.

“I’ve made no secret of it with the ministry and relevant ministers that I’m interested in seeing if we might follow the Victorian model and get a little more teeth to recommendations.”

At present, coronial services are provided by the chief coroner, 15 coroners and support staff . For the year ending June 30, coroners took jurisdiction of 3320 cases as well as providing advice on a further 2633.

I’m unsure about whether making it mandatory for agencies to respond is a good idea. Of course all recommendations should ideally be considered, but a formal response to 3,320 cases a year (not sure how many involves recs) could involve a lot of bureaucracy.

But even putting the number aside, a related issue is the quality of the recommendations. Each coroner is independent and can recommend anything. The job of a coroner is to focus on reducing deaths, but not on getting the balance of risk right, and this means some recommendations are impractical or worse. As an example, the Herald reports:

A coroner has recommended that a licence should be needed to hire nail guns – a move labelled an overreaction by DIYers.

And many recall the seat belts for quad bikes recommendation. Do we need a government department to really look into the pros and cons of needing a licence to hire a nail gun? I’m unconvinced.

What could be a partial solution is to have recommendations go to the Office of the Chief Coroner, and ones that are endorsed by him or her, then need a response?


Coroner say Chris Kahui did it

July 26th, 2012 at 7:00 am by David Farrar

Stuff reports:

The Kahui twins met a violent death while in the sole care of their father Chris Kahui, who went on to lie repeatedly to protect himself from blame, a coroner has found.

Mr Kahui, who was found not guilty of the murder of sons Chris and Cru in a 2008 High Court trial, has rejected the findings outright and reaffirmed he denies any involvement in the untimely deaths of his babies.

A report released today by coroner Garry Evans finds that Mr Kahui was alone with the 3-month-olds for at least three minutes on the day they received their fatal injuries in 2006. …

The coroner’s finding states: “The court is satisfied . . . to the required standard of proof, that the traumatic brain injuries suffered by Chris and Cru Kahui were incurred by them during the afternoon/early evening of 12 June 2006, whilst they were in the sole custody, care and control of their father at 22 Courtenay Crescent, Mangere, Auckland.”

Despite family wanting to take the babies to hospital after the incident, Mr Kahui refused. …

Mr Evans finds that, during the resulting police and coronial investigations, Mr Kahui repeatedly lied and changed his evidence.

“The evidence given by Chris Kahui was unreliable, conflicting and, on many occasions, untrue. The court [meaning Mr Evans] formed a poor view of his credibility.

Not as good as a criminal conviction, but at least the truth has been established by the Coroner.