From numbers to names
Within a week all 51 victims of the Christchurch shooting were returned to their families. Tommy Livingston looks at how was this achieved.
The country’s coroners were in a conference room in the Christchurch Grand Plaza Hotel when a gunman began opening fire a short drive away at the Al-Noor Mosque.
About 3pm that Friday, March 15, the group said their farewells and went their separate ways, unaware of what was happening nearby.
Coroner Sue Johnson was driving home when she heard on the radio that nine people had been killed in a shooting. She pulled over and called Chief Coroner Deborah Marshall, whom she had just farewelled.
They discussed what might happen next. If more people died then a mass-fatality incident would need to be declared.
That would set in place a series of events which would require a team of police, pathologists and coroners to respond.
Marshall, who was sitting at Christchurch Airport, planned to go back to Auckland until further information became available.
A mass-fatality incident is declared in only very specific circumstances. The information so far did not meet the criteria.
While Marshall was in the air, the head of the National Initial Investigation Office (NIIO), Merelyn Redstone, received a call from police.
‘‘They did not know how many people were dead but they knew it was a lot,’’ she recalls.
With the chief coroner on a plane, Redstone phoned Deputy Chief Coroner Brant Shortland, who agreed that the way things were developing an announcement would need to be made.
Redstone split her NIIO team in two so people could begin to work on the information soon flowing in from police.
It had been the busiest week of the year, with 133 deaths already recorded with the office. Things were only going to get busier.
When Marshall landed in Auckland she was briefed – there was now enough information to declare a mass-fatality incident. The last time that happened was after the 2011 Christchurch earthquake.
Around the country a team of people readied themselves to respond to the chief coroner’s call. Over the following week they worked against the clock to return the victims of the shooting to their loved ones. Their aim was to turn numbers into names.
Ground zero
The deceased lay where they had fallen. The terror which had gripped the rooms hours before, when a man walked in firing, had been replaced by a still silence.
Outside, the country, and the world, was coming to terms with what had happened at the Al-Noor and Linwood mosques. Inside, a team was working quietly to collect evidence and document the destruction.
Sergeant Phil Simmonds was leading the police’s input for the Disaster Victim Identification process (DVI).
The meticulous five-step exercise begins at the scene with the unnamed deceased, and ends – it is hoped – with the identification of that person and the return of their body to their family.
In a mass-fatality event, all victims begin as unknown, unnamed people. The DVI process, followed the same way globally, aims to make sure beyond a shadow of a doubt that the right identity is assigned to the right body.
In the case of the mosque shootings, authorities were dealing with what is known as an open scene – a situation where an unknown amount of people could have been killed – as opposed to a plane crash where there is a record of victims.
Police were compiling a list of names from concerned husbands, wives, parents and children gathered at the cordon, all trying to find their family members.
Once the scene was secured and safe, photographs were taken of the victims where they lay, along with personal property. The bodies and property were then assigned an individual DVI number.
Under Simmonds’ watchful eye, the team worked diligently to make sure this was done for each body and body fragment.
It is a grim task, which Simmonds has carried out across the world. After the 2004 Boxing Day tsunami, he had been part of an international contingent tasked with trying to identify thousands of victims.
While each job is different, Simmonds says the DVI process follows the same rigorous pattern. One step at a time, a jigsaw puzzle is slowly pieced together.
‘This couldn’t be happening’
At the newly built justice precinct, a short drive through Hagley Park, Redstone was setting up the centre that would deal with the administrative arm of the process.
There is always a lag of information with a mass-fatality event as it takes time for police to document everything before that data is passed on, she says.
This allowed Redstone time to organise the installation of computer systems, catering, and the booking of hotels. Finding accommodation for the influx of staff who would be responding to the event was challenging.
As had happened with the earthquake, media companies had been the first to book hotel rooms.
‘‘We offered our home, but you don’t really put a judicial officer in your home.’’
Due to the lack of accommodation, on the Friday night, some coroners had to stay at a motel just four doors from one of the mosques.They were moved as soon as other options became available.
On Saturday morning, Redstone’s husband was charged with helping ferry people from the airport into the city – taxis were hard to come by.
When the chief coroner arrived, a meeting was held outlining how the next few days would progress. The DVI process was well known by many in the room as a result of the earthquake.
Those spoken to for this article lived in Christchurch and responded following the earthquake. Immediately following the shooting there was a sense that this ‘‘couldn’t be happening again to Christchurch’’, Redstone recalls.
Unlike 2011, the city’s infrastructure was intact and the casualty number much lower.
During the earthquake a makeshift mortuary was set up at Burnman Military Camp. This time, the core of the work which flowed from the shooting would take place out of the Justice Precinct and the hospital mortuary.
While the DVI process cannot be rushed, there was an awareness that the bodies had to be returned as quickly as possible due to Islamic faith traditions, Redstone says.
Days earlier, at the conference in Christchurch attended by all coroners, a session had been held on how best to engage with Muslim communities.
It was presented by a member of the community who spoke of the importance of 24-hour burial timeframes and other cultural norms. That information quickly become relevant.
From the mosque to the mortuary
Less than 24 hours after the first shot was fired, the mortuary phase of the DVI process began.
Once removed from the mosques, the bodies of all 51 victims were placed in refrigerated storage. To create extra space, temporary storage containers were placed outside the backdoor of the mortuary.
The room was set up with two sets of five gurneys, each one marking a different stage in the process. The first gurney was for property, jewellery, personal effects and clothing which had been removed from the deceased. Each object was labelled with the same
DVI number of the body it came from.
The items were photographed before removal and, once removed, cleaned, rephotographed and secured alongside the deceased.
The next gurney was for taking fingerprints and footprints. The bodies were then moved to the third gurney, where an external examination was carried out by the pathologists. Scars and tattoos can offer clues as to who the deceased is.
Autopsies were then performed, with any surgical removals – such as the appendix or gall bladder – noted. Anything which can assist the coroner to establish the identity is recorded.
The exact cause of death is also investigated to assist with a criminal prosecution.
Usually the family have a right to object to a full autopsy, but where a loved one has died as a result of alleged criminal activity, they have no say.
On the fourth gurney the full dental examination takes place. Forensic odontologist Dr Viv Levy was one of 18 dental experts who worked following the shootings.
The mouth is a map often revealing key information which helps to establish an identity. With people who suffer catastrophic injuries, even the smallest bone fragment or tooth can shed light on who they belong to.
‘‘You cannot skip a step,’’ she says. ‘‘If you are not methodical and careful big mistakes can happen. There are many examples overseas where the wrong person is identified. It is awful.’’
No assumptions can be made. Everyone is nameless until that name can be confirmed to the highest standard.
Even a victim who is carrying photo identification can’t be fully identified, Levy explains. ‘‘What if, prior to them being killed, they saw a wallet had been dropped on the ground in the commotion and picked it up? You just don’t know.’’
The final step is where paperwork is completed and quality control done.
At the same time as the mortuary process was under way, Simmonds’ team was collecting antemortem evidence. This involves interviewing victims’ families to get information about identifying features as well as retrieving DNA evidence from hair brushes, or fingerprints from their homes.
Antemortem evidence can come from the most unlikely of places, coroner Sue Johnson says. In some cases footprints have been taken from the walls where children have put their feet, or from the bottoms of showers.
‘Brightness in the flowers’
The sea of flowers which grew each day along Riccarton Ave reminded Redstone why she was going to work. In the week after the shootings she would drive past the makeshift memorials.
While nobody knew what she was doing, the flowers made her feel like people were silently encouraging the DVI team. ‘‘Seeing those flowers did something to my heart,’’ she says. ‘‘It was sobering. There was a lot of love in the brightness of those flowers.’’
At the justice precinct, Redstone controlled the spreadsheet tracking all that was happening. Each DVI number assigned to a body or body fragment was entered into the spreadsheet, along with the suspected names of the deceased.
The aim is to match a name with the DVI numbers.
With the Christchurch earthquake there were far more DVI numbers than names because of the amount of body parts. With the shootings, the disparity was far less.
Following the earthquake, there were 44 bags of body parts which were unidentifiable. As hard as the team tried, there was no way they could comfortably identify who they had come from.
Some families who had received the majority of their loved ones’ bodies did not want to get further parts periodically as they were identified. ‘‘We always want to get that loved one back. My staff are dedicated to making that happen,’’ Redstone says.
At the same time, car crashes, suicides and other sudden deaths meant outside Christchurch the already-stretched coronial system needed to continue to operate.
Given the Christchurch mortuary was at full capacity, those who died on March 15, or after, in Canterbury had to be transported to other mortuaries in the surrounding regions.
The same problem was faced following the earthquake. Families who had people die unrelated to the disaster were sometimes left feeling those deaths were less important.
‘‘The earthquake and the March 15 deaths were important in getting loved ones back,’’ Johnson says. ‘‘However, they were no more important than the other deaths across the country.’’
A job well done
The dust had barely settled following the 2011 earthquake when political pressure began bearing down on the walls of the makeshift mortuary in the Burnham Military Camp.
Those inside were dealing with the biggest mass-fatality incident on New Zealand soil in 80 years. Outside, prime minister John Key was asking why it was taking so long for bodies to be returned to families.
Key’s remarks were quickly criticised by international experts who knew the DVI process should not be rushed. He later backtracked on his comments.
Following the shootings, those who had worked through the earthquake knew it would not be long before questions were being asked about why the bodies could not be released sooner.
The reality is, Johnson says, that many people do not understand the DVI process. ‘‘It is understandable. Why would they?’’
Many people assume they can visually ID their loved ones themselves, but with people who have suffered horrific injuries that can be difficult.
And as Johnson points out, there is endless evidence to show that even family members can wrongly identify someone in the aftermath of a mass fatality incident – especially if the injuries have been severe.
Chief Coroner Deborah Marshall gave regular media briefings to assure the public that everything was being done to get the bodies returned – ‘‘in a culturally appropriate way’’.
Later, it was revealed that four days after the attack some grieving families threatened to march in protest due to the time it was taking to release the bodies. ‘‘We spoke to them, calmed the crowd down and gave them updated information,’’ Police Deputy Commissioner Wally Haumaha told
Others publicly asked Prime Minister Jacinda Ardern to make the process go faster.
Away from the glare of the cameras, the reconciliation stage of the DVI process was beginning.
The strands of postmortem and antemortem evidence were pulled together to reveal the tapestry of a person’s identity. That information was then put to the coroners in a formal identification hearing.
Once the coroners were satisfied that the identity of a body, or body part, had been confirmed, they could order the release to a family.
In one instance, the footage broadcast by the alleged gunman was used to help confirm the identity of a bone fragment.
Because of the number of fatalities in such a small space, it was not always easy determining which fragments belonged to whom.
‘‘Seeing [the footage] helped us to identify who it belonged to. We would have never known otherwise,’’ Johnson says.
During the identification hearings, she or her colleagues would sit in a pseudo courtroom.
After reading, or listening, to the evidence, the coroner makes a determination. If they aren’t satisfied, then the DVI commander is tasked with producing more evidence.
That did not happen after March 15, according to Johnson, but occurred twice following the earthquake.
By March 21 – six days after the mosque shootings – almost all of the victims’ identities had been confirmed. Each time a DVI number matched a name, smiles were shared around the room. That was what teamwork achieved.
‘‘For us to put a name to a DVI number is us giving a loved one to a family,’’ Redstone says. ‘‘It is really important to us. To care for those who are grieving.’’
Coroner Johnson, along with others in her team, attended the funerals one week after the shooting. As crowds milled around, they left to finish the last hearing of the 51 victims.
Within a week they had returned the bodies of all those who died to their families.
‘Of course it is sad’
From time to time a face will pop into Sue Johnson’s mind, reminding her of a case she once worked on.
As a coroner, you get to know some of the intimate areas of a deceased person’s life. ‘‘We get to know what these people looked like, but we don’t know who they were in the day-to-day.
‘‘The photos we have of them [gathered during the antemortem phase] with their families and friends I can see in my mind’s eye. Of course, it’s sad.’’
Strong protocols around supervision make debriefing a normal part of the DVI process. The team which responds to massfatality events often shares a camaraderie.
Following the 2011 earthquake, army padres at the Burnham Military Camp would walk around the makeshift mortuary checking to see if those working closely with the dead were coping. A simple pat on the shoulder was often enough, Johnson says.
‘‘Sometimes things do get under the radar, that is true and normal.
‘‘My outlet is long-distance running and road biking. Running up a hill you can’t really think about anything else.’’
There will be lessons from how the DVI process was carried out for the mosque shootings.
As of this year, coronial kits for a mass-facility incident have been put in place around the country. They include paperwork and instructions to help coroners, who may be isolated, begin their work as quickly as possible.
Levy, the forensic odontologist, says that she will see someone she worked with on the DVI process and just share a glance. There is a subtle acknowledgement that you have worked through something unique together.
Humour is also important, she says. While the nature of the work isn’t fun, everyone still tries to smile.
Redstone agrees. While the circumstances are terrible, the work is rewarding. Names turned into numbers, returned to names again. ‘‘Everybody’s loved one is extremely important to them. If you or I lost a child they are important to us.
‘‘We want to make sure people are treated how we would want our family treated.’’
‘‘If you are not methodical and careful big mistakes can happen. There are many examples overseas where the wrong person is identified. It is awful.’’