Coroners court: An inquest into families’ long waits

With 14 lawyers at one inquest and waits for answers that stretch into years, Nikki Macdonald investigates whether the coroners court is delivering grieving families a fair deal.

They found Nicky Stevens’ body on the Thursday. On Monday morning, the coroner’s office called. ‘‘We thought, gee, they’re really on to it,’’ says Nicky’s dad, Dave Macpherson. ‘‘It’s not going to be like these other cases – we’re going to have a quick hearing. That was in March and they were talking about late that year.’’

The police investigation set them back about nine months. Then there were so many lawyers involved in the inquest that they lost another nine months finding a date on which they could all attend. Then there were no free courtrooms in Hamilton. How about we shift it to Rotorua, they said. How about we don’t, Macpherson replied.

All the while, Nicky’s parents put their own lives on hold. They postponed family holidays in case the dates might clash with the coroner’s hearing. The years ticked by – one, two, three.

‘‘You can’t get it out of your mind,’’ Macpherson says. ‘‘You wake up halfway through the night feeling angry and wanting to leap out and write something down so you don’t forget it.’’

‘‘The toll has been huge,’’ says Nicky’s mum, Jane Stevens. ‘‘Our family has struggled to keep going. Our health has suffered greatly. Our [other] son’s life has suffered enormously. We haven’t been able to move on. It’s always there. It’s always just lurking in there in front of you the whole time.’’

In June – more than three years after Nicky’s death in March 2015 – the couple finally sat in the coroner’s court, listening for answers about the suspected suicide of their 21-year-old son. What they heard instead sounded more like butt-covering, from those in whose care he died.

Instead of giving evidence at an inquisitorial process designed to find the truth, they felt bullied and belittled by a lawyer whose only role seemed to them to be to defend the psychiatrist responsible for Nicky’s care.

‘‘He cross-examined Jane and I as though we were suspects in a murder trial,’’ Macpherson says.

Stevens goes further: ‘‘Trying to make out that actually you got that wrong, or you’re not a very credible witness, all of those things that are typical to prosecution and defence lawyers. It’s totally inappropriate in that environment.

‘‘It’s more like a court of law than it is an inquisitorial process

. . . There’s no way on this planet that process can ever get to the truth of what happened.’’

Every year coroners look into about 3400 deaths – everything from deaths in state care to car crash victims, to suspected suicides, to deaths that are simply unexpected and unexplained.

The cases are handed to one of 18 coroners – lawyers who decide whether an inquiry is needed to discover how the person died, and what lessons might be learnt and recommendations made.

Every week, month and year of delay is lost time to make improvements that could prevent other deaths.

Take the 2015 death of three members of a Southland family – eventually attributed to a faulty kettle catching fire. There were 66,000 of those kettles already in Kiwi homes and they remained for sale until The Warehouse voluntarily withdrew them seven months later. Had they waited for the coroner’s findings, the kettles would have been sold for another two years.

As veteran lawyer for families Nigel Hampton, QC, puts it, ‘‘meanwhile harmful practices often continue without change or abatement or improvement – other deaths and/or injury may well result meantime. Why change something when no-one has pronounced you wrong? Bureaucratic inertia wins every time.’’

A 2016 law change was supposed to speed up the process, by cutting the number of mandatory inquests and reducing duplication with other agencies. But figures obtained under the Official Information Act show delays have instead got worse.

The coroners court has a target of 70 per cent of open cases being less than 12 months old. In 2017-18 more than four out of 10 cases were older than 12 months – the worst rate in six years. That’s 723 grieving families waiting more than a year for answers.

The average time to close coronial cases is 345 days, but that masks long inquest waits, because more than 90 per cent of cases are decided without a hearing.

The Justice Ministry could not say how long cases requiring an inquest took, but Stuff’s analysis of 70 published decisions from 2017 found those cases took more than twice as long – an average of two years. The longest – the death of Grant Smith in a car crash involving a driver who had a seizure – took 41⁄2 years.

Asked if it’s acceptable for families to wait years for resolution, Hampton says, ‘‘Emphatically no’’. ‘‘Families’ sufferings should not be needlessly extended. Coroners must take proper control of their procedures and remember the importance of timeliness. They need to crack the whip. And their verdicts should not be long-reserved and awaited works of art.’’

Lawyer Antonia Fisher, QC, who has represented families at coroners’ hearings for 20 years, says inquest delays are understandable when there’s a criminal process or major