‘Enough is enough’: Six years and still no coroner’s report

Monday, 22 April 2024

Judy Jeffery has been waiting six years for a coroner's report into her husband's suspected suicide in 2018.

Judy Jeffery wanted to wait for the coroner’s report into her husband Richard’s death before scattering his ashes. She never imagined they’d still be in her lounge six years later.

The “ridiculously talented” Hawke’s Bay mechanic died in February 2018, a month before his 50th birthday, of suspected suicide. There have been no coroner’s findings, and no explanation for the delay.

“I don’t feel like he’s at rest or at peace, and nor am I, because we haven’t reached that end point,” Jeffery said. “Enough is enough. Six years is far too long.”

When Jeffery decided to wait until the coroner’s report before scattering Richard’s ashes, she thought it might take a year. Six years later they’re still languishing in her living room.

Jeffery is one of 3570 grieving families who, by the end of December, had waited more than 12 months for answers about their loved one’s death.

After multiple “fob-offs”, she complained to her local MP, and Chief Coroner Judge Anna Tutton. Now they say Richard’s case will be transferred to another coroner ‒ her fourth.

Seeing coroners’ reports released into much more recent deaths, Jeffery wonders whether suspected suicides are shoved to the bottom of the priority list.

Despite increased resources, Coroners Court waiting times continue to blow out. In 2023, the average time to close a coroner’s case needing an inquiry was 1024 days ‒ a 77% increase from the 579 days it took in 2018.

The number of coroners has more than doubled, from 18 in 2018 to 37 now. Tutton said it was too early to measure their impact, but the extra staff were freeing up existing coroners to focus on complex cases, by taking on the 24/7 duty coroner role.

But seeing comparatively speedy coroners’ findings into other deaths, such as traffic accidents, Jeffery questioned whether Richard’s case was treated differently.

“Is there a stigma to the suicide that means it takes longer? That they just cast them aside and forget about them?”

Of the coroners’ reports released so far in 2024, 25 of the 29 deaths were more recent than Richard’s. The earliest death was in November 2013; the most recent was from January 2023.

While the two most-delayed reports were both suicides, there were also two reports into suicides in 2020 and two from 2021.

Jane Stevens has been advocating for suicide-bereaved families since the death of her son Nicky, including laying out shoes to represent each life lost to suicide. (File photo)

While some suicide cases are complex as they involve deaths in state care, or an extensive history with mental health services, Richard had not sought mental health help. While he was unhappy at work, there were no obvious red flags or missed opportunities. So Jeffery is not expecting great revelations from a coroner’s investigation.

“Nothing is going to bring him back … Let’s just tick that box and it’s done.“

Jane Stevens was a whānau advocate for a report into the experience of suicide-bereaved families in the Coroners Court. Her son Nicky took his life in 2015, while in the care of a Hamilton mental health unit.

Delay loomed “huge” in whānau concerns about the process, she said.

“It’s ridiculous, when there’s actually more coroners now, that the length of time is getting longer and longer. That’s not acceptable.”

However, each case was so unique that it was hard to say whether suspected suicides were put in a too-hard basket, Stevens said.

The whānau report was produced by the Suicide Prevention Office. Amid questions about the office’s future, and the replacement of former director Matthew Tukaki with “government seat-warmers”, Stevens feared both the report’s recommendations ‒ and progress on prevention ‒ would be shelved.

“On the ground, we’re not seeing that much change, and it ain’t good enough. People are still dying. And people are still suffering the consequences of that. And it’s not OK.”

The Coroners Court is clear that suicides are not treated as any less important than other deaths.

Asked how older cases are prioritised, the court provided no evidence of any system. They instead reiterated that the circumstances of some deaths took longer to investigate and some inquiries were delayed by investigations by other agencies, such as the Health and Disability Commission, WorkSafe, or the Transport Accident Investigation Commission.

Families may also raise issues requiring further investigation or expert evidence, the court said.

None of those applied to Richard Jeffery’s death.