Does the system work? Reflections of a 28-year coroner

When Wallace Bain ruled the suicide of Nicky Stevens in the care of Waikato DHB was avoidable, the lawyer for the DHB complained to the solicitorgeneral.

He alleged Bain had a pre-determined view and asked for another coroner to review the case. It’s a symptom of the change in attitude to coroner’s investigations since Bain began the job 28 years ago. ‘‘It has certainly become far more serious – far more lawyered up, if you like.’’ He acknowledges a lack of resources has meant fewer inquests and long delays.

Some argue the court’s influence is weakened by the fact it can only make recommendations, not enforce change. But Bain believes coroners still make a difference.

There were the three treacherous one-way bridges at Benneydale, near Te Kuiti, that were widened to two lanes, after Bain told the Transit NZ boss he could be liable for manslaughter if he ignored warnings of the fatal risk. Repeated inquest warnings about co-sleeping helped cut sudden infant death numbers from about 60 to six a year; inquiries into texting, bullying, forestry and hunting deaths led to law and culture changes to reduce the risks.

One regret is the fact his recommendation for a register of children aged under five, which he suggested following the death of Nia Glassie and repeated in the findings for Moko Rangitoheriri, was not adopted.

‘‘We register births, but then nobody knows where that child is for five years til they’re supposed to go to school... If they were registered, the ministry or Plunket or someone could call on them. If anyone had gone into the house where Nia Glassie was, she would never have died. They would have found what the hell was going on immediately.’’ While the increasing role of lawyers makes the process look more adversarial, the inquisitorial structure still makes the Coroners Court unique, Bain says.

‘‘You must have that independent authority that has that inquisitorial power to cut through a lot of the nonsense that goes on and get to the heart of the matter. That’s the power the Coroners Court has that other courts don’t.’’