Coroner's Court failing bereaved families and the public - chief coroner

Thursday, 16 September 2021

The long time it takes for coroners to deliver reports into sudden deaths has been called a 'national scandal' by one grieving wife. (First published January 2021)

The overloaded Coroner’s Court is failing bereaved families and the public, the chief coroner admits in a briefing paper.

The May briefing paper, by Chief Coroner Deborah Marshall, said long delays could “retraumatise whānau” and make coronial recommendations “redundant”.

“Coroners universally express concern about their inability to release findings within a reasonable timeframe because of their workloads,” wrote Marshall, who is stepping down next year.

The number of unresolved coroners’ inquiries is expected to blow out by 400 in the next three years, despite last year's appointment of eight new part-time coroners.

Chief Coroner Deborah Marshall has admitted the coronial system is failing families and the public.

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The pressure to reduce caseloads meant fewer deaths were investigated through public inquests, which fell four-fold from 2008 to 2017. Inquests provided higher quality evidence and better recommendations to prevent further deaths, Marshall said.

“The current coronial system, and its resourcing, fails to meet the needs of bereaved families and the public,” she concluded in the paper, obtained under the Official Information Act.

The average time to close a coronial case increased 42 per cent between 2018 and 2021, from 321 days to 455 days. Cases needing an inquiry take an average of 877 days, and those going to inquest take 1451 days.

With 18 full-time coroners and eight part-time relief coroners, the court could not keep up, Marshall wrote.

Carey and Owen Hume, parents of Erica who died of suspected suicide in the mental health ward at Palmerston North hospital in 2014.

“It is not possible for the current number of coroners to keep file numbers static, let alone decrease them.”

Coroners deal with 200-300 cases at a time, and every time they serve as duty coroner, or conduct an inquest, their caseloads continue to increase.

The Coroners Act allows for up to 20 full-time coroners, but Marshall pointed out that cap was set when New Zealand’s population was 4.2 million and there was no requirement for a 24/7 duty coroner.

Marshall’s briefing outlined pages of proposals to improve the system, which have been blacked out.

QC Anne Stevens says long delays bring the court into disrepute and more coroners are clearly needed. (File photo)

Marshall’s revelations come as no surprise to grieving families, who have been speaking for years about the trauma of coronial delays.

Carey Hume thought she would finally get answers when an inquest date was set for November, seven years after her daughter Erica died of suspected suicide in Palmerston North Hospital’s mental health unit.

However, Covid-19 lockdown delays mean it will now be heard early next year.

While it was some comfort that Marshall acknowledged the impact of delays on families, Hume worried any proposed solution would include further reducing inquest numbers, to save time.

“What concerns me, is that it will be an excuse for them to shut out families even more …The family needs to be able to hear the people speaking and explaining what happened, and have the ability to ask questions.

Minister for Courts Aupito William Sio has said reducing the Coroner’s Court case backlog would be his main focus this term.

The most traumatic thing for families, was the same issues coming up again and again, Hume said. More permanent coroners – and support staff – were needed to reduce delays.

Carey’s husband Owen also called for coroners’ recommendations to carry more weight, to be recorded in a public register, and to be chased up to ensure changes were made.

Dunedin QC Anne Stevens, who represents families in the Coroner’s Court, said long delays had been a problem for years.

“You get all these ramifications, of people dealing with unresolved grief, anger and frustration. It brings the whole service into disrepute.

“Then you've got a client who is as much distressed by the process, as by the death. Because it is sort of degrading or demeaning of the kin, if they are not heard … and delay of being heard is just as bad as not being heard.”

Stevens said coroners had huge workloads and were unfairly blamed for ballooning backlogs when resources were the main issue.

With enough coroners, cases not involving criminal investigations should be completed in 6-12 months.

Extra temporary coroners could reduce the backlog, to give breathing space to improve the process, she said.

Minister for Courts, Aupito William Sio, said he was considering operational and legal improvements.

He had directed the Justice Ministry to look into the Chief Coroner’s proposals, but some would depend on the budget and the government’s lawmaking programme.

“I can promise you that I want to progress these changes as quickly as possible”

The Justice Ministry acknowledged growing case delays and said it was working alongside the Chief Coroner to find ways to reduce them.