It's called progress

Heather Ayrton served as the Hokianga's coroner for many years. Photo / file

It's difficult to recall exactly when common sense and local knowledge lost their currency in this country, but it was quite some time ago. In local government it happened in 1989, with Roger Douglas' amalgamation of councils. In the Far North's case two boroughs and four counties became the Far North District Council, despite strong objections from Kaitaia and the Mangonui County, which had been successfully operating a joint administration for some years.

They pleaded for permission to form one new entity of their own, which would have meant minimal change, but were overruled by the Local Government Commission.

That decision might have been influenced by a strained relationship between the Mangonui County in particular and the commissioner who was in charge in these parts. Some councillors clearly expressed their reluctance to accept instruction on how to do their job by a man described by one as a former school teacher, a barb that some believed cooked the two councils' goose. The decree that the new authority was to be based in Kaikohe for at least the first decade was widely regarded as being made out of spite.

Whatever, the days when councillors were allowed to exercise their wealth of local knowledge were over, elected members being reminded, in the late Dennis Bowman's case repeatedly, that they were not there to address purely local issues but to take a broader governance view.

The promised economies of scale proved to be an illusion, in part perhaps because a large and growing bureaucracy cannot replace the local knowledge that once heavily influenced councillors' decisions.

That might have been the beginning, but the process of replacing local with something supposedly better has continued, and examples of where that has failed to produce the promised benefits are not hard to find. The latest to hit the limelight is the coronial system.

There was a time when even small communities had their coroner, often a local lawyer. What is now the district council's Te Hiku Ward was for many years well served by Ian Rasmussen, who was succeeded by Robin Fountain. Kaikohe and the Hokianga were equally well served for decades by Heather Ayrton, a journalist by trade, who was highly regarded, and appreciated, in her coronial role.

Rasmussen and Fountain would generally open an inquest into an unexpected or accidental death within hours, days at most, of death, to establish the identity of the deceased. The process would then be adjourned sine die (indefinitely), resuming when the information needed to reach a conclusion, and perhaps make recommendations, was to hand. That would often be a matter of weeks, perhaps a few months, and was generally speedy and effective.

The writer isn't sure of Fountain's practice, but Rasmussen often made decisions in relatively straight forward circumstances 'on the papers,' without a formal hearing. He would inform the local newspaper when he had done that, so it could report his findings before he dispatched said papers to wherever they had to go.

Some circumstances were more complicated than others, but the system was relatively expeditious, empathetic, and, most importantly, played an important role in helping those who were grieving to understand what had happened and 'move on,' as they say.

The system we have now does none of those things. It is slow, cumbersome and bureaucratic, to the benefit of no one. This newspaper will not be alone in coming in for strong criticism from families, angry and upset that the death of their loved one has been raised again years later, reviving their distress.

Pointing out that the newspaper was simply doing its job, and that the problem lies with a sluggish coronial system, doesn't cut a lot of ice.

The problem goes further than that, however. Last week it was revealed that the glacial pace at which the system functions has prevented any accurate evaluation of the progress that might, or might not have been made in reducing the rate of cot deaths, or sudden unexplained death in infancy (SUDI) as it is now known.

In 2017 the then National-led government set a target for reducing the SUDI rate, then reportedly the highest in the developed world, by 2025. Three years later neither the government nor anyone else, is able to say if that has been achieved, because the coronial system is unable to produce the statistics needed.

Those who were working to reduce the cot death rate were described as "flying blind" because of a huge backlog of investigations.

That is disgraceful, not only because of the impact delays are having on research and measures that are now well in place in the hope of reducing the rate at which infants are dying. It must also be multiplying parents' and families' grief many times over.

Unexplained though some circumstances might be, the death of an infant, judging by the writer's experience, is often not complicated. There is no obvious reason why the coronial process should be so slow, unless, as stated, it is simply overloaded or hamstrung by bureaucracy to the point where it cannot function effectively.

Professor Ed Mitchell, an infant death researcher at the University of Auckland and member of an expert advisory group on SUDI, would not agree that the circumstances of a cot death are not necessarily complicated - he was quoted last week as saying that there was always a delay because of the complexity of the investigations - but he could not recall a time when they were so far behind.

Selah Hart, CEO of the national service for SUDI prevention Hāpai Te Hauora, said the Ministry of Health's provisional monthly data on SUDI deaths were not robust enough to base prevention measures on, and while she declined to say what those data showed, she hinted that SUDI rates were not falling.

According to the Ministry of Justice, it takes an average of 479 days to close a coronial case, but cot deaths can take longer because underlying conditions and other potential causes must be ruled out before they can be confirmed as a SUDI.

That takes a bit of believing though. A post mortem is still a post mortem, undertaken within days, at most, after death, while many sudden unexplained infant deaths are not unexplained at all. In the years prior to 2017, more than half of babies who contributed to the SUDI rate were found to have been accidentally suffocated by parents while sharing a bed. That was a particular hazard for Māori and Pacific families, whose babies were also at greater risk because of high smoking rates in pregnancy.

Without up-to-date data, however, no one can say whether health messages and resources are reaching the families who need them, and if they are, why they are not being adopted.

The fundamental role of the coronial system, surely, is to determine whether the cause of any death might offer lessons that will help save the lives of others. This current system is obviously not achieving that. We will never return to the system we once had, but this regime simply isn't working. It needs an inquest of its own.