Coronial errors rekindle parents' grief
When Julie Duffy lost her only child to suicide the day after his 21st birthday she never thought she would have to relive the "overwhelming grief".
But in the following months a series of mishaps sent her and husband John repeatedly "back to day one", beginning when she received a template autopsy report labelled as her son's.
Craig Duffy took his own life in his hometown of Alexandra on December 20, 2012.
He was a "social, fun-loving" arborist, who had plenty of friends and a canine companion who went everywhere with him. His treasured dog died without warning three days after he did.
The family's ordeal with Coronial Services began three months after Craig's death, when Julie Duffy came home from work to find her son's full autopsy results in her letterbox.
While initially upset at the lack of forewarning about the documents, there was worse to come when she opened the envelope.
The results were that of a full autopsy, when they had asked for a limited one. However, the first page had Craig's name and description on it.
"I just lost it," she said. "It was like day one again. I was totally distraught."
A desperate Julie Duffy and her funeral director spent the afternoon with her case manager, who initially denied there had been any mistake. She then rang the embalmer to ensure a full autopsy had not been carried out.
"[The case manager] said it must have been a computer template error. But then he said it was the pathologist's mistake and he's on holiday."
The Duffys were eventually told a computer template had been "cut and pasted incorrectly" into the report.
The days that followed were a "complete nightmare", Duffy said.
"We never had any assurance that no-one else received Craig's file. We wanted to ask what [the pathologist] had done to make sure it never happened again."
Duffy did not receive an amended report for another month.
Dr Alex Dempster, the pathologist in charge of Craig's file, met the Duffys to personally apologise after the error.
He told The Press the mistake was "entirely mine for which I have fully accepted responsibility".
"Measures have been taken to ensure that such an event never occurs again and it was purely the result of an oversight on my part," Dempster said.
The Duffys then wrote to Chief Coroner Judge Neil MacLean to have Craig's file transferred to Dunedin, under the care of another coroner.
However, there were more mistakes to come. When they received the coroner's findings in October 2013, there were four errors in the first paragraph. His occupation, address, living situation and date of death were incorrect.
"I was just so exhausted by the whole process, you just get so worn down by it. We had to deal with all of this unnecessary s..t on top of losing a son."
In the year to June 2013, 541 people committed suicide in New Zealand.
Judge MacLean conceded mistakes "happen occasionally", but said it was Dempster's first that he was aware of. "The only control I have over the pathologist is I have to approve them.
"I need to have a look at whether this error justified him being taken off the list, and I justified that it didn't.
"He stepped up to the mark and took full responsibility. I can't ask much more than that."
Annually, more than 6000 deaths are reported to a coroner - roughly equating to 17 or 18 a day, MacLean said.
The introduction of the Coroners Act 2006 in July 2007 overhauled the system, meaning the 63 part-time coroners around "every little town" in the country became 13 fulltime coroners.
The three coroners in the South Island became four shortly before Christmas 2013 with the addition of a North Island-based "virtual" coroner, due to the volume of deaths occurring in the south.
"Seven years on, it's still being fine-tuned," he said.
While New Zealand had sufficient coroners for the workload, Judge MacLean said they were "always struggling" to maintain enough pathologists.
He encouraged families finding the process hard to deal with to contact their coroner for help.
"We aren't experts in suicide prevention. All we can do is call it like we see it. We don't mind if people complain. It's actually better if they do because we can find out what went wrong and make sure it doesn't happen again."
Duffy has since joined lobby group Community Action on Suicide Prevention, Education and Research (Casper), travelling the South Island to support bereaved families as a volunteer.
She was now campaigning for better suicide prevention education, and an overhaul to the Coronial Services process.
"I just thought, there has to be something good come out of the worst possible thing you can imagine in your life.
"This isn't to apportion blame. At the end of the day it's too late for us but it isn't too late to help make a change."