Death duty: A day in the life of a coroner

Wednesday, 3 April 2019

Deputy Chief Coroner Brandt Shortland says he is worried that coroners are working too hard, too often.

Twenty four hours a day, seven days a week, a duty coroner is at work helping deal with sudden deaths across the country. The work is gruelling and gruesome. Tommy Livingston reports on how the system works, and the challenges coroners face.

Death had been at work long before Deputy Chief Coroner Brandt Shortland got to the office.

The cogs of the coronial system had not stopped moving throughout the night, and a list of people who had died over the past 12 hours was waiting for him.

Looking through the work for the day, Shortland finds a photo of a man whose face decomposed before his body did. 'This is the kind of stuff we have to deal with,' he says.

While on shift, he is in charge of deciding what happens to the recently departed. The duty coroner's office manages a case from the time police report the death until the body is released from the mortuary. It is a different type of work to his normal coronial duties.

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The small team of coroners across New Zealand examine the thousands of deaths which are reported to them each year. From that number, they decide whether further investigation is needed and if an inquest should be held. Along with ruling on the cause of death, they are also tasked with finding out if anything can be learnt from someone's demise.

Criticism has long been levelled at the slow speed cases often move through the coronial system. It is not uncommon for some families to wait years for their loved ones' case to reach an inquest. However, today, in Shortland's office, things are moving fast.

Outside his door in a colourless building in Ellerslie, Auckland, sit the National Initial Investigation Office (NIIO). A team of people who man the phones 24/7 as notifications of sudden or unexplained deaths come in. They triage what needs to be done and when, by the duty coroner.

Today's list consists of suspected suicides, a suspicious death, heart attacks and more. When a person dies suddenly, attending police decide if the coroner needs to be notified.

That notification goes to NIIO, who then start the process of getting the information to the duty coroner who rules on whether a post-mortem needs to be done and if further coronial action is required.

Shortland's time is split between signing off paperwork so bodies can be returned to families, advising doctors who are reluctant to sign death certificates and working to make sure formal identification is done properly. This can be tricky when someone has severe injuries or has decomposed – as one NIIO worker says: 'Heat is not our friend.'

Myriad tasks means it's not uncommon for Shortland to be chained to his desk for the majority of the shift. He hopes that by the end of the day – when he hands over the reins to another duty coroner – the cases are progressing well, or have been resolved.

HARD DECISIONS

Today, he is dealing with a woman who died hours earlier in a car crash. A child, who was also in the car, is fighting for their life in hospital.

The police have indicated to Shortland they want the woman to have a forensic post mortem – the most intensive type of procedure. But the family don't want her body touched. This, Shortland says, isn't uncommon.

'You are trying to marry up the law with human nature, and it is not always a perfect fit.'

When a family objects to a post mortem, the coroner embarks on a negotiating exercise. Usually, loved ones are objecting on cultural or religious grounds. Shortland says finding a solution quickly is a balancing act.

Shortland says more resources are needed to make the coronial system more efficient.

If the cause of death is obvious, and not suspicious, then sometimes police will agree that a less invasive postmortem can be done – which doesn't involve opening up the body – or sometimes, no post mortem at all.

If there is suspected criminal activity, then a post mortem is always conducted, and the family has no grounds to object.

'Police will stand their ground when they think it is a little bit suspicious,' Shortland says.

'We look at a way where we can satisfy what the legal requirements are and also try and uphold the beliefs of the family.

'Most of the time there is a common-sense solution.'

After some back-and-forth with police, Shortland decides a lesser post mortem will be sufficient. Moments later, a woman from NIIO tells Shortland that the young child who was also in the car has died.

Shortland pauses to take in the news.

'That family has been through enough,' he says.

'WHEN IT HITS YOU, IT HITS YOU'

The hours are long, and at times the work is close to home. Shortland – a former defence lawyer – is usually based out of Northland and says it is not uncommon for people to call him directly when a family member dies.

When he was appointed coroner, he made a point of spending time visiting local marae and other community centres.

'It's important to understand your audience,' he says.

In his sparse office, a single photo hangs on the wall of himself and some colleagues when he was appointed coroner in 2007.

'I had less greys then, this is what the job will do to you.'

He's joking, but he knows the nature of the work is harsh. The pace of the duty coroner's office is dizzying, and as Shortland moves between cases quickly, he recalls some from the past 10 years which made his eyebrows raise and those who were hard to stomach.

Today's workload includes a man who may have died from erotic asphyxiation.

'You talk to cops who will say that death is cumulative. Eventually, it takes its toll. We all deal with it in different ways. I mow the lawns.'

Shortland says he never forgot the advice one senior coroner from Australia gave him at his induction.

'He said the moment you stop feeling things is the moment you should move on. We are not exempt from the same issues other people face. When it hits you, it hits you.'

A SYSTEM UNDER PRESSURE

The 24/7 duty coroner roster is shared between the 17 coroners across the country. It had been 18 until earlier this year when Hawke's Bay-based coroner Christopher Devonport died.

The duty coroner works from their office, or, if it is after hours, from their home. This takes them away from their usual coronial caseload which, according to Shortland, is around 250-340 cases per coroner.

'The closing of the files is what you are trying to concentrate on. But the front door is open as duty coroner, and the work keeps pouring in. It is like having two jobs.'

This process is stunted even more because a coroner's leave does not accumulate. While it is vital to take breaks, it is difficult to pause a case when you know a grieving family is waiting for an answer, Shortland says.

Brandt Shortland says dealing with death constantly does have a cumulative effect.

Add into the mix sickness, bereavements and family commitments and further hold ups are inevitable.

Last year, 5608 deaths were reported to Coronial Services – an increase on the 5564 deaths the year before. Trying to fix the system as the caseload climbs would take one thing: resources.

According to Shortland, only an increase in coroners and case managers would put a dent in the mounting pile of work. The Coroner's Act 2006 stipulates there can only be twenty full-time coroners at one time.

'If they could reduce the caseload to 120-150 per coroner, the turn around would be a lot quicker. It isn't rocket science.

'Certainly another three coroners would help.'

While it seems the system is only treading water, Shortland says they managed to handle the recent response to the Christchurch terror attacks well.

Chief Coroner Judge Deborah Marshall told Stuff it was too early to tell if the work created from the attack would cause further delays.

'While many coroners were in Christchurch, the duty coroner system continued to run for the rest of the country,' she says.

It has been over ten years since the coronial system was overhauled and the new Act put in place.

Shortland believes given there the decade's worth of data, now would be a good time for the Ministry of Justice to review how the duty coroner system is working, and how the wider service is coping.

He worries that coroners are working too hard, too often.

In the meantime, the phone is ringing – it's a pathologist wanting to discuss the results of a post mortem. Emails are piling up as more notifications come in. And in between tasks, Shortland remembers he hasn't had time to eat.

'One of the things we all enjoy is giving families closure,' Shortland says. 'Finding out what the issues were and sorting it out.

'Every now and again you get a family who comes back with a letter, note or email saying, 'Thank you so much'. That is enough to keep you going.'

WHERE TO GET HELP:

1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor

Lifeline – 0800 543 354 or (09) 5222 999 within Auckland

Youthline – 0800 376 633, free text 234 or email talk@youthline.co.nz or online chat

Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)