‘It’s just a mockery’ ‒ the ‘ridiculous’ wait for Coroners Court answers
Sunday, 7 April 2024
Grieving families still face torturous waits for answers from the Coroners Court, despite staff and funding boosts. The court argues it’s too early to measure the impact of the changes. But others say the overly legalistic court needs a bigger overhaul than just more staff. Nikki Macdonald investigates.
When Erica Hume died in 2014, her mother Carey thought it might take two years for the coroner to investigate what happened. Three “at the ridiculous most”.
In May, it will be a decade since the 21-year-old died of suspected suicide at Palmerston North Hospital’s mental health unit.
Yet still her family waits for answers. For the day they can open their email without wondering if it will throw them back, yet again, to all those horrible details.
The inquest into Erica’s death was held in August 2022, but now they’re waiting for the coroner’s written findings.
“Ten years is just beyond comprehension,” Carey Hume says. “If the purpose of the coroner’s inquest is to find out what happened, to make changes, and to stop it happening again, it’s just a mockery. And it’s insulting to the families and friends, because if you truly were trying to address the issues, it would become a higher priority, and a laser focus.”
Carey and Owen Hume are just one of 3570 families who, by the end of December, had waited longer than a year for answers about how and why their loved one died.
In 2023, the average time to close a coroner’s case that needed an inquiry was 1024 days ‒ a 77% increase from the 579 days it took in 2018.
Cases like Erica’s, where an inquest is held so the coroner ‒ and whānau ‒ can hear witness testimony and ask questions, take 2033 days (5½ years) on average.
For years, officials, politicians and the chief coroner have acknowledged that long delays re-traumatise families and risk any resulting recommendations being so outdated they’re redundant.
The Coroners Act even explicitly states that coroners ”must perform their duties without delay”.
The court has had funding and staff boosts, starting with eight part-time relief coroners appointed in 2020. But still the delays have grown. So what is going on?
The terrible toll of delay
Allan Bennett also uses the word ridiculous to describe his seven-year wait for coroner’s findings.
He was shunted between three different coroners, before Coroner Mary-Anne Borrowdale finally released her damning findings into the 2016 suicide of his son Kodi in prison.
Bennett says while Borrowdale was “awesome”, the delay was “bloody ridiculous”.
“You don’t seem to go anywhere. Your mind is still going, you still flashback all the time. You have to live with it for that bloody long.
“People shouldn’t have to wait for anything like this. It’s your life as well. It ages everybody. It kills you. We all end up with stupid disorders and sleepless nights.”
And by the time any findings and recommendations come out, they’re already way outdated, Bennett says.
And then there’s the erosion of evidence.
Hume says for those giving evidence at Erica’s inquest, “I can’t recall” provided a convenient out for difficult questions.
“As a family, that is perhaps the most insulting thing of all. To say you can’t recall what caused the death of your loved one, is actually quite unacceptable, really.”
Why are we waiting?
The ballooning delays and backlog boil down to one thing ‒ every year, the Coroners Court takes on more cases than it closes.
The reasons for that are harder to unpick. Briefing documents mostly blame overloaded coroners for the delay. The court is also buckling under growing numbers of unexplained deaths that turn out to be from natural causes, but chew up Coroners Court time reaching that conclusion.
Former coroners have said juggling the duty coroner’s role ‒ which involves 24/7 cover to process new cases ‒ is like having two jobs and takes them away from ongoing investigations. They’ve also said one major case can stop their entire office.
But while deaths such as Erica Hume’s and Kodi Bennett’s are complex, recent long-delayed findings include cases that appear straight-forward. Such as the death of 18-year-old Olivia Keightley-Trigg, who was killed in August 2018, when her car collided head-on with a ute driving on the wrong side of the road.
A serious crash investigation was completed, and by November 2019 the other driver, Kevin Bishell, was convicted of dangerous driving causing death and jailed for 2½ years.
But it took another four years, and “pass-the-parcel” between three different coroners, to finally get a decision. The six-page findings, released in February, made no recommendations and concluded that Olivia “died of injuries sustained in a motor vehicle crash”.
“I think that was what annoyed me more than anything else,” says Olivia’s mum, Suzie Keightley. “We waited 5½ years to find out the same thing we got told the day she died, by the police.”
As in many recent findings, Coroner Ian Telford apologised for the delay. But Keightley says no-one could ever explain why it was taking so long. Especially given the facts had already been compiled for the criminal case.
“Somebody has gone to court, been charged for it, gone to prison, served his sentence, is out and we still haven’t received that information.”
Keightly never expected the coroner’s findings to bring closure: “There is no closure on grief”. And the family was lucky the court process had already cleared Olivia of fault. But the endless delay added to the stress.
“It was just the frustration of constantly waiting.”
Hume says in Erica’s case, the legalisation of the process contributed to delays, with institutions lawyering up to defend themselves. At one stage at the inquest, she counted 18 lawyers in the room. Just trying to find a time that suited everyone was a challenge.
Lawyer Nigel Hampton, KC, who has often represented families at inquests, says some of the ballooning delay seems to stem from the changing nature of the Coroners Court. What originated as a lay court that held jury hearings almost immediately after death has morphed into a fully-professional, and overly formalised, court.
“It’s not supposed to be a court of rules and formal procedures. It shouldn’t be by design, and it shouldn’t be by practice.”
Increasing use of counsel assisting the coroner and competing expert witnesses also add delay, Hampton believes.
He has also noticed an increase in unnecessarily detailed findings, sucking up time he believes could be better invested hearing more cases.
“What used to be comparatively short, hard-hitting and incisive reports now become compendious judgments… The conclusions and recommendations, I suggest, could be achieved in a much more direct and simple way, with the same result.”
What has been done?
This is not a story about pleas falling on deaf ears.
In 2020, eight part-time relief coroners were appointed to ease the workload of the then 18 permanent coroners. (In 2021, officials warned the new additions would not cut the case backlog.)
In 2021, then courts minister, Aupito William Sio, declared that reducing Coroners Court waits was his priority. At Budget 2022, he announced $28.5 million over four years to fund four extra permanent coroners, seven coronial registrars and four clinical advisers to “ease workload pressures”.
Sio promised recruitment would start for the four extra coroners immediately after the law was changed to increase the maximum number of permanent coroners from 20 to 22 (documents show they originally planned 23). But while the law was changed in May 2022, the four extras were not sworn in until nearly 18 months later.
The April 2023 Coroners Amendment Act then created the new job of associate coroner, to free up permanent coroners to focus on complex cases. Seven associate coroners were appointed in late 2023 and early 2024.
That brings the total number of coroners to 37 ‒ a massive increase on the 18 coroners in 2018.
The chief clinical adviser was appointed in March 2023, and seven clinical advisers started between August and October that year. Their role is to help weed out natural-cause deaths and prevent them clogging up the court.
But still the backlog has grown.
Chief Coroner, Judge Anna Tutton, was not available for an interview, but says it’s too early to measure the impact of the court’s extra resources. She’s optimistic the associate coroners will reduce delays, by taking over duty coroner responsibilities and working on old cases.
Tutton acknowledged the stress of delay on grieving families.
“I am committed to ensuring the Coroners Court puts people first, that our processes are fair and transparent, and that families and whānau involved in the coronial system are able to participate in a meaningful way.”
The Justice Ministry’s briefing to the incoming minister notes the number of coroners’ findings issued each month increased by 12% between January and September 2023, and August 2023 heralded the largest monthly drop in active cases in more than 10 years.
But by the end of the year the court still had 6161 open case files, of which 58% were older than a year. The Justice Ministry says the trend looks positive, as open cases fell 3% to 6191 in 31 January 2024, compared to 6393 in January 2023. But that’s still more open cases than the month before.
Hampton isn’t confident extra staff will fix the ongoing delays.
“Throwing more resources at it may assist in some areas. But it doesn't solve the fundamental problem of it getting bogged down in procedural issues.”
The case for change
As well as extra coroners and support staff, then minister Sio promised a wider review of the whole coronial system. (The Justice Ministry says this is not currently underway.)
One thing Keightley wants improved is communication with families. No-one explained the coronial process, or prepared her for the letter that arrived out of the blue detailing the car crash’s impacts on her 18-year-old daughter’s body.
“The hardest thing, from our perspective, was we’d never had to deal with a court process, we’ve never had to deal with a death like that, and you’re learning. And nobody gives you any information.”
A 2023 report into the experiences of families who lost a relative to suicide recommended “emotional, legal and navigation support” and an online portal to keep whānau updated. (The Justice Ministry has now produced a video to help families navigate the process.)
Like Hume, who contributed to the report, families talked about the toll of delays, and the court’s legalistic feel.
The Coroners Court is supposed to be an inquisitorial court – a truth-finding mission led by the coroner. As opposed to an adversarial criminal court, in which lawyers for the prosecution and defence build competing cases.
“It was supposed to be inquisitory, but it felt adversarial,” commented one whānau member. “It was a legal argument not a human one,” said another.
“There was so much uncertainty and anxiety while waiting for answers,” added another.
Some questioned whether lawyers were needed at all in an inquisitorial, fact-finding process. Others suggested their numbers could be capped.
The report also suggested a system to audit whether organisations act on coroners’ recommendations, and a mechanism for enforcing them.
Hume wants a mandated time-frame to decide cases ‒ maybe two or three years. And if anything runs over that, there should be compulsory progress reports every three months.
“It just keeps falling down the ladder of cases otherwise, and I think that’s not acceptable.”
Former chief coroner Deborah Marshall’s 2021 briefing paper noted the number of inquests had plummeted in the rush to clear cases, and that they were the gold standard of inquiries, resulting in better evidence and recommendations.
For the Humes, the inquest was a precious part of the process they would not want curtailed, as it gave them the chance to ask questions.
“At least we walked away feeling like we got Erica’s side of the story out.”
And while there might be straight-forward cases, such as traffic accidents, that could be siphoned off to a different body to reduce pressure on coroners, Hume would not want to see deaths of the vulnerable in state care, whether that’s hospitals or prisons, removed from the coroner’s jurisdiction.
Hampton would like the court stripped back to its origins ‒ a coroner personally inquiring into a death and making findings as quickly as possible.
The one thing everyone agrees on, is that leaving families hanging for years is not acceptable.
“Coroners have a role to speak for the dead, and the longer it takes for them to speak for the dead, the worse the trauma for the families that wait to hear what has happened,” Hampton says.
TIMELINE OF EFFORTS TO REDUCE CORONERS COURT WAITS
May 2019 ‒ Justice Minister Andrew Little announces $7.5m over four years to fund eight new part-time relief coroners. He expects them in place in 3-4 months.
March 2020 ‒ Eight relief coroners finally appointed. Officials warn in 2021 they won’t cut the backlog of inquiry cases.
Budget 2022 ‒ Courts Minister Aupito William Sio announces $28.5m over four years to fund four extra coroners, seven coronial registrars and four clinical advisers to “ease workload pressures”.
May 2022 ‒ Law change increases cap on permanent coroners from 20 to 22 (original plan was 23).
March 2023 ‒ Chief clinical adviser appointed.
April 2023 ‒ Coroners Amendment Act introduces associate coroner role.
August-October 2023 ‒ Seven part-time clinical advisers start (equivalent to four full-time).
October 2023 ‒ January 2024 - Extra four permanent coroners finally sworn in, almost 18 months after law changed to allow their recruitment. Seven associate coroners also sworn in.
BY THE NUMBERS (as at 31 December 2023)
6161 active coronial cases, up from 3161 in 2016.
3570 active cases older than 12 months, compared with 1676 in January 2018.
58% of cases are older than a year.
The oldest coroners case is 4898 days old (that may be delayed by other external investigations).
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