The coroner will see you now

The Monday Extract: Christchurch coroner Marcus Elliott writes a personal essay about death, grief, and mercy in a new book about dying in New Zealand.

Across New Zealand on a Saturday morning, people are playing netball or cricket, mowing the lawn, buying fruit, reading the paper, checking Facebook, living life. I am at my desk at home. I started duty at 5pm yesterday. Since then I have spoken to doctors, police officers and a pathologist, and I have directed three post-mortems. I was woken at 2am to speak to a doctor about a child who had just died. There’s no such thing as real sleep when you’re the coroner on duty, only periods of reduced alertness.

This became my way of life on March 23, 2015. Before that day, I was a practising lawyer. Over the years, I had worked in law firms and then as a barrister in chambers. One of the privileges of being a lawyer (and there are many) is the opportunity to help people at the time they need it most. Perhaps the most appealing thing about being a lawyer, and the feature which attracts many to the role, is being able to speak on behalf of people who, for some reason, are not able to speak for themselves.

Becoming a coroner meant that I would have the chance to apply the skills and experience I had gained in legal practice. More importantly, it presented the opportunity to help people and to contribute to society. As the Chief Coroner in Ontario has articulated, a coroner speaks for the dead to protect the living. The role is unique within the justice system: the coroner finds facts and conducts inquiries as opposed to presiding over disputes.

In its report on coroners the Law Commission outlined how their responsibilities reflect the concerns of the state: “Protecting the lives of its citizens is a primary function of the State. Its processes for investigating sudden death ideally should be geared to finding the causes and eliminating them for the future, while respecting the sensibilities of the family in its grief. The State takes a vital interest in ascertaining, as precisely as possible, the cause of all deaths so that suspicions of foul play, homicide or neglect of human life can be fully investigated. The underlying objective is to identify practices that have cost human lives and then to modify or eliminate them.”

So my life as a coroner began when I entered a courtroom that day in March. Many people I know were confused and even concerned that I had decided to become a coroner. “Don’t coroners just deal with death all day?” I was asked. “Why would you want to do that? It seems like a strange thing to do.”

The only way that a case can end up before a coroner is by a person dying. Every one of the files in my office relates to a person who has died, leaving behind a family, friends and unfulfilled goals and dreams. It would be natural to dwell on the pain and grief that each of those deaths has caused. It is always tempting to reflect on your own mortality or, given the inevitability of death, to contemplate the great joy and utter meaninglessness of, for example, a sunrise. But it wouldn’t be possible to do this job if this was how you spent your working day.

There are people in our society who deal with death regularly. Police officers and paramedics see death in all its immediacy and indignity. Doctors see patients die. Pathologists perform post-mortems. Funeral directors embalm bodies. No one could do this work if they allowed fear or fascination with death to descend on them for too long. From my point of view, death is only one part of a much larger story. Death is a doorway to learning about people and about our society.

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Like many other countries, New Zealand keeps records about how people die. This means that it’s possible to identify common causes of death and publish information about how to minimise the risk of dying prematurely. For example, heart disease is the main cause of death in New Zealand. Lung cancer is also a significant cause of death, and the leading cause of cancer death in New Zealand.

Deaths due to “natural causes” are usually not addressed by coroners. In about 80 per cent of deaths, a person’s treating doctor will be able to identify that an illness caused their death, in which case they will sign a certificate, which describes the cause. Death must be reported to the coroner when the cause is unknown, when it is self-inflicted, unnatural or violent.

About 5500 deaths are reported to coroners each year. Of these, coroners accept jurisdiction of around 3400. Post-mortems are carried out in many of these cases, the results of which may show that the death was due to natural causes. The other cases relate to deaths due to medical treatment, transport accidents, assaults, death in prison, fire-related death, workplace accidents, choking, falls, overdoses, death during childbirth, infant death, natural disasters and suicide in its many manifestations.

Death can arouse much curiosity, especially when it is sudden and unexpected. Sometimes a person’s death can lead to rumours or suspicions within a community. The coroner’s function is to determine the cause and circumstances of the death and, if possible, to address any suspicions or rumours. The coroner must also consider making comments or recommendations to reduce the chance of death occurring in similar circumstances.

The coroner has the power to direct a post-mortem examination, otherwise known as an autopsy, to assist in determining the cause of the death. It is the process in which a pathologist, who is a medical specialist, examines the body internally in search of the traces that death may have left on the body. These traces may be clear to the naked eye (for example an occlusion in an artery of the heart or a clot in the brain) or they may be microscopic. The pathologist is like an investigator, searching the body for clues and then trying to make meaning of them.

After becoming a coroner I decided that, if I was going to direct post-mortems, I would need to understand what actually happens. The only way to do this was to watch some. I have seen a number of post-mortems now, on people who have died in many different ways. It is a confronting and visceral experience to watch as a body becomes the sum of its parts.

The information available before the post-mortem may have given the pathologist a sense of what to look for. If there are injuries to the body which are thought to have caused death, these may be the focus. If there was a history of heart disease, the heart and the arteries around it will be a point of attention. In a suspected hanging, the injuries to the neck are important. Are they consistent with hanging? Do they match the ligature which was used?

The Coroners Act requires the coroner to consider a number of issues when deciding whether to direct a post-mortem: whether the death was violent and, if so, whether it was due to the actions or inactions of other people; the existence of allegations, rumours, suspicions or public concerns about the death; the desirability of minimising distress or offence to people who, by reason of their ethnic origins, social attitudes, customs or spiritual beliefs, find post-mortems offensive or require bodies to be available as soon as possible after death.

In these situations, there may be a collision between society’s interest in identifying the cause of an unexpected death and the family’s objection to the prospect of their partner or parent or child undergoing an internal examination. For example, in the case of a baby who is found dead in a bed, there may be a public interest in knowing what the cause of death was, especially if the circumstances of death seem to be suspicious or if identifying the cause could help us learn about how to prevent similar deaths. This must be weighed against any objection from the family, for example on cultural grounds, and it is usually necessary to talk to the family to explain the process and hear their concerns.

Thus, I have found myself in my study at home, talking on the phone to young parents in the early hours of the morning about whether their baby should undergo a post-mortem. Nothing in my years of legal practice equipped me to do this.

One of the oddities about being duty coroner is that, from a legal perspective, you have custody of the body of every person whose death has been reported to the coroner. This means that, as I sit at home while on duty, I am the legal custodian of dead bodies all around the country. The police, funeral directors and mortuaries hold the bodies on my behalf. I must decide where the body can be taken and who is authorised to view it. Families are often anxious to see the body of their loved one and this can usually be facilitated, although it can obviously be distressing, especially when the deceased has suffered serious injuries. Once the post-mortem is finished, the body cannot be released to the family until the coroner has authorised it.

The coroner is required to determine the circumstances of a person’s death, as well as the cause. There is no definition in the Coroners Act of ‘circumstances’, so the coroner will need to decide what is relevant. This will depend on the type of death. If a person dies by suicide, it may be relevant to inquire into the nature of any mental health care provided in the months, or even years, before the death. If a person dies in a motor vehicle accident, it may not be necessary to look any further back than the day of the accident.

One of the most important coronial functions, and the one which probably attracted me to the role above all else, is the need to consider comments or recommendations to reduce the chance of death in similar circumstances. This function distinguishes the Coroners Court from virtually every other court. While other courts determine disputes between parties, the coroner must consider the ways in which society can learn from sudden, unexpected or violent death.

Coroners have made comments and recommendations about matters such as medical and surgical care, infant deaths, deaths in custody, drowning, drugs, alcohol and substance-related deaths, falls, fire-related deaths, homicide and interpersonal violence, mental health issues, natural disasters, self-inflicted deaths, transport-related deaths and work-related deaths.

However, at the heart of every coronial case is a grieving family. Grief affects people in very different ways. Some families want as much information as possible and then to participate in the coronial inquiry, as is their right. Others do not wish to participate at all and do not even respond to correspondence. Again, that is their right.

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.”

These words remind me of the reasons why I chose to end my career as a lawyer and take on a new life as a coroner. It does seem like a strange thing to do. Death is a constant presence and the work is difficult. It takes its toll in ways that are difficult to convey. It is a role in which few could say they have not shed tears after talking to a family or walking out of a court after an inquest. It is possible to leave the workplace but not possible to forget photographs of a dead child. And no one can be more aware of their own mortality, and that of their family, than a person whose daily work involves death.

But it is a role in which every coroner has willingly taken on, and it is a privilege. So, when my life as a lawyer ended, a new life opened up in which there is great opportunity to help others, to search for truth and to try to improve society. I consider myself lucky to have been given the opportunity.


From Death and Dying in New Zealand edited by Emma Johnson (Freerange Press, $30), featuring essays by a cemetery manager, grief expert, palliative care worker, Steve Braunias, and others, available at Unity Books.


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