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and all sorts of people before you.’’
Bain hopes the extra part-time coroners will help, but says his gut reaction is that more will be needed to cut the backlog.
But it’s not just obviously complex cases that take years to resolve. Coroner’s findings published this year included a scuba diver running out of air, which took almost three years to investigate.
The findings into the death of Daryl Murray, who died of a known side effect of schizophrenia drug clozapine, took 31⁄2 years. There was no inquest and Murray’s mother Jen Rutgers – who Murray lived with and who would often go with him to mental health appointments – feels she never got to have her say.
‘‘It’s been quite traumatic actually. For 31⁄2 years I had a death certificate for him that said ‘referred to the coroner’... I would have liked to have been allowed to go to that final hearing... I don’t know if it would have made any difference, but it would have made me feel better.’’
Marshall acknowledges a ‘‘significant backlog’’ of cases, partly because the Coroners Court took on 200 more cases in 2018/19. Of those, 51 were mosque shooting victims, but the reason for the other 150 is unclear.
‘‘Once the newly appointed coroners are up to speed and we are at full strength, I expect to see the backlog of cases reduce,’’ Marshall says.
The Coroners Act allows for up to 20 full-time coroners. At present we have 17, with recruiting continuing to replace the 18th.
Asked if he was considering appointing extra permanent coroners to reduce delays, Little said only that the new relief coroners would help reduce the backlog.
Corinda Taylor has lost track of how much they’ve spent on lawyers. But she knows it’s too much – they had taken on a lawyer and barrister for the coroner’s investigation, but just couldn’t afford it.
The family had already spent $30,000 on a lawyer for the Health and Disability Commission investigation into the 2013 suspected suicide of
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Instead, she now has to go through Ross’ records, again and again, writing submissions with no legal expertise. Taylor took a 3834-signature petition to Parliament in December calling for more coroners and free legal representation for suicide-bereaved families.
She is getting some pro bono legal help, but most families are not so lucky. Unless the dead person was the victim of a crime, legal aid for coroner’s investigations is means-tested and may have to be paid back.
‘‘It is brutal on families to have to compete in the legal field, when we ourselves don’t have any legal training or expertise. It’s a complicated process, but it’s also traumatising.
‘‘I can’t tell you how many times I’ve had to go through the medical file and each time we are given a deadline to deliver our response. It causes flashbacks, it gives me sleepless nights. I feel vulnerable. It’s just really, really upsetting to go through the whole process over and over and over again.
‘‘It’s a fight to get support. It’s a fight to get justice. And it’s tiring on families. Most families just give up and walk away, because it’s just too hard. And that’s how the truth gets covered up.’’
Carey wrote to Little in October 2018, also calling for free legal help for bereaved families, especially when their loved one has died while in the care of a mental health unit.
‘‘Why are families having to incur debt just to get answers about what happened to their loved ones while in state care? It’s mind-boggling to me.’’
Na Nagara agrees coroner’s investigations are difficult for the families of suicide victims, and an advocate or representative would help.
‘‘It is kind of self-evident that a bit of support would help families.’’
Bain also believes that, in cases stacked with high-powered barristers, families should get funded lawyers.
The Justice Ministry’s 2018 legal aid review found means testing thresholds were too low. Little says making sure people can get legal support is an
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‘‘access to justice issue’’.
‘‘Ensuring people can access justice is important to me. I have indicated to my officials that I am interested in looking further into legal aid policy for coroners’ proceedings. I expect advice following the election.’’
Suicides appear among the most difficult coroners’ cases, especially for bereaved families like the Taylors, Humes and Grays. Because they have usually been involved in the person’s medical care, they inevitably become involved in the investigation into their death. Which means ripping off that scab again and again.
A priority for the new Suicide Prevention Office is to investigate whether there’s a better way, na Nagara says.
‘‘It’s an extraordinarily difficult process for bereaved families to endure.’’
The review is expected to kick off in the next 12 to 18 months and will canvas the views of everyone from coroners and investigating agencies to grieving families.
One reason agencies lawyer up and become defensive, which adds to delays, is society’s blame culture, na Nagara says.
‘‘A coronial investigation or a review into any suicide should never be about attributing blame, but somehow it gets transferred into that. This idea that suicide is a simple matter – that if a clinician had done a, b or c this person wouldn’t have ended their life. That over-simplification of the context of suicides contributes I think to that really unhelpful idea that we have to hold someone responsible.’’
For the father of Nicky Stevens, Dave Macpherson, being able to speak in public at the coroner’s inquest was worth the wait.
‘‘We felt that we went to the right place. It was appalling that it took so long...The big thing was that we felt we had got our story out.’’
And that’s all Carey wants – she’s not looking for blood or blame. She just wants to stand in court and tell the world Erica wanted to live.
‘‘I just want her to have that moment where they pay attention, and she’s heard.’’