The role of the coroner was perfectly encapsulated in a speech by the Honourable Sir David Baragwanath, who said: “[A Coroner has] two vital roles: to give the living the comfort that comes from closure; to know how and why a loved one has suddenly died. The other is to preserve life: by learning from the sudden death then speaking truth to power, however unpalatable that truth may be, so that disaster is turned to good.”
The Coroners Court has jurisdiction under the Coroners Act 2006 to investigate unexpected, unexplained, or unnatural deaths, and to make recommendations or comments that may prevent further deaths in similar circumstances. The coronial system is a 24-hour service, where there is always a coroner on duty to receive reports of deaths.
Their work is grinding and relentless. There is little relief for ‘Death’s Auditor’.
Currently, the coronial bench comprises twenty-six coroners, (18 permanent and 8 relief). The 2022 budget announced funding to appoint four new permanent coroners and support staff together with funding to establish seven coronial associate/registrar roles and four clinical advisor roles to assist with the considerable workload pressures. In addition, the Ministry is progressing work to review the terms and conditions for coroners, which includes considering issues of parity between coroners and judges, and issues of parity between relief coroners and permanent coroners.
About 5700 deaths are reported to coroners every year and coroners accept jurisdiction for around 3600 of these deaths. Once a death has been reported, the duty coroner decides whether to accept or decline jurisdiction. If jurisdiction is accepted, the duty coroner’s responsibilities include considering whether a pathologist is directed to perform a post-mortem examination to help establish the deceased’s cause and circumstances of death. Duty work often involves the coroner engaging directly with doctors and pathologists as part of their initial investigations. The last step in the duty process is to direct the release of the body to family after proper identification of the deceased has been established.
Duty coroner work is both challenging and rewarding. It requires significant stamina from the coroner who can be woken in the middle of the night to progress matters even after completing a nine-hour duty shift. After the release of the body, the file is assigned to a receiving coroner in one of four regions across the country. That coroner is responsible for deciding whether to direct further investigations, open an inquiry, or hold an Inquest before making their findings and closing the file. Between 1 July 2021 and 30 June 2022 there were a total of 3066 cases closed by a coroner where jurisdiction was accepted, with less than 1% of them having an inquest, with all other findings being made on the papers in chambers.
The Coroner plays an important and too often unheralded role in both the health and legal systems of Aotearoa. As independent judicial officers serving the Crown and the public it has always been Coroners, that openly and fearlessly speak for the dead so as to protect the living. This judicial service takes great character, courage, stamina and wisdom. However, their tried and tested assets of openness, of compassion, of problem solving, of truth speaking must be fully supported by governments that not only recognise the Coroners calibre but also resource their mahi beyond mere rhetoric.