Report highlights failings of coronial system

02:46, Jul 18 2014

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.

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.

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.

Improvements to the coronial system - to make the process faster and more effective - were announced by Courts Minister Chester Borrows last year.

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."

MacLean said although there had recently been an effort to pool reports so that a broad-reaching recommendation could be made - for example, about co-sleeping or cycling - there would always be differences between cases and in coroners' opinions. "Sometimes you just have to keep plugging away, calling it as you see it."

The proposed bill is expected in Parliament before Christmas.

New Zealand has about 29,000 deaths each year, of which about 20 per cent are reported to coroners. The study looked at 607 findings into deaths, resulting in 1644 preventive recommendations that were sent to 309 individuals and organisations since the New Zealand Coroners Act came into force in 2007.




In the past five years, there have been at least six calls from different coroners to make lifejackets compulsory for people on small boats, and half a dozen more comments on the importance of wearing them. It wasn't until this month, after the release of a report on the death of Taita man Leon Scurrah in 2012, that Transport Minister Gerry Brownlee asked for policy advice for a law on mandatory lifejacket-wearing.


There have been at least 15 recommendations or comments from coroners since 2008 about the importance of education on the dangers of sleeping with a baby, particularly after the parent has been drinking alcohol. Coroners have made numerous calls to step-up awareness campaigns on safe sleeping practices for babies and parents. Other recommendations have been about smoking, leaving children to sleep in strollers or car seats, on couches, or the dangers of infants going to sleep on their tummies. Last year, deaths from co-sleeping was termed an epidemic by coroner Wallace Bain.