Once upon a time, communities had their own coroners. It was a good system. Generally the role was filled by a local lawyer - in the writer's experience what was then the Mangonui County benefited greatly from the services of Ian Rasmussen, who was succeeded by Robin Fountain, while the Hokianga was served with distinction, for many years, by a journalist, Heather Ayrton.
These people might not have had much, if any, medical expertise, but what they did have was local knowledge. The system was efficient, attuned to the community it served, and far superior to the one we have now.
As so often seems to happen, with increasing regularity, change was made in the name of progress. We now have full-time coroners, scattered around the country, often at great distance from the communities where lives have been lost in circumstances that demand an inquiry, not only to formally establish the cause of death but often to determine whether lessons can be learned in the hope of preventing similar deaths in the future.
This new, 'improved' system is cumbersome, can be dreadfully slow, and often seems to lack the fundamental wisdom that was such a feature of what we once had. To be fair, it can result in coroners delving much more deeply into the circumstances of a death, but the writer's experience suggests that the ability or desire to search for answers to pertinent questions was rarely lacking in the old days. The system changed not because there was anything wrong with the old one, but was born of a mistaken belief that a higher level of expertise and efficiency was needed, and could be achieved.
There might be no grounds to question the expertise of those who now serve as coroners - certainly their findings tend to suggest that they are commendably assiduous in seeking answers to every possible question - or of their sympathy for the families and friends of the deceased, but one might rightly ask, on occasion, whether they are doing as good a job as those who preceded them.
The inquest into the death of 54-year-old Palmerston North man Wairongoa Clarence Renata, who drowned after going to the rescue of his daughter at Cable Bay on January 2, 2018, is a case in point, not only for the fact that Coroner Mary-Anne Borrowdale's findings were released more than three years after the event.
The circumstances of Renata's death were not complicated, although, to her credit, Borrowdale left no stone unturned in her efforts to establish not only what had happened but how Renata's death might have been prevented. The upshot of that included the finding that the Far North District Council could take a degree of blame, given that it had made no effort, or insufficient effort, to warn the public of the potential dangers of swimming at Cable Bay.
The council had little option but to respond as it did, saying it welcomed Borrowdale's findings and recommendations, and that while it had no statutory responsibilities to mitigate water safety risks, and its staff were not qualified to make such assessments, it acknowledged that there was a gap in the information available to beachgoers at unpatrolled beaches.
In line with the coroner's recommendations, it had commissioned signs that would be erected on council reserves at popular beaches in the Doubtless Bay area, including the Cable Bay reserve and Little Cable Bay, to alert visitors to the variable conditions at those beaches. Another sign would be erected at Cooper's Beach, and two more at Tāipa, and additional information highlighting dangers would be added to existing signs at those and other beaches.
Where required - it isn't clear who will determine that - more warning signs would be erected at popular beaches to highlight risks associated with swimming at those locations.
There will always be doubt regarding just how much notice people take of signs, however. In most cases probably very little, if any. The provision of flotation devices at beaches deemed to be potentially dangerous would be more effective, and perhaps add weight to warning signs, and these are now available at Cable Bay and elsewhere, thanks to the community's immediate response to Renata's death.
That might well require ongoing attention and effort, given that flotation devices have had a habit of disappearing in the past, but could well save lives in years to come. Borrowdale's criticism of the council seems harsh, however. As chief executive Shaun Clarke pointed out, the council does not have the expertise of the likes of Nick Mulcahy, aquatic risk manager of Surf Lifesaving New Zealand, whose told the inquest that Cable Bay was a 'waved-dominated reflective' beach that was prone to sudden changes in water depth close to the shore, changing waves, rips and currents.
The combination of waves, an incoming tide, rip currents and sudden changes in water depth posed considerable risks on the day Renata died.
Was the council really expected to be aware of all that? And did Surf Lifesaving New Zealand have a moral duty, at least, to inform it of those potential dangers? Could Borrowdale's accusation that the council had been complacent have been better aimed at SLNZ?
The fact is that, whatever waring signs might be displayed, people put themselves at risk on beaches every day. The children who got into difficulty at Cable Bay on January 2, 2018, probably shouldn't have been in the water at all given the conditions, and it might be that warning signs would not have kept them out.
There is a bigger issue.
Years ago, Robin Fountain conducted an inquest into the death of a young man who was fatally injured whilst riding his motorbike in the dunes at Tanutanu, an area that was, and probably remains, popular with those who like to get their thrills on two wheels. Fountain expressed the deepest sympathy for the young man and his family, but resisted the urge to suggest that others stay away from the dunes.
The Far North, he said, offered wonderful opportunities for a range of activities, many of which were accompanied by a degree of risk to life and limb, and while it would be wise for those who made the most of those opportunities ensured that their wits were unimpaired, it would be wrong to recommend that they be avoided because, for some, there would be a high price to pay.
It was a long time ago, and Fountain's wise words do not spring to mind, but effectively he was saying that the potential for tragedy was the cost of living within a wonderful natural environment.
If someone was to die at Tanutanu in such circumstances today, the presiding coroner would, without doubt, recommend that riding bikes there be banned. Or at least that warning signs be erected at appropriate locations.
Fountain's decision all those years ago made the case for local coroners most eloquently. It was a perfectly rational and reasonable expression of the view that life cannot be lived, certainly not lived to the full, without risks. We should accept those risks as a fact of life, while taking reasonable measures to minimise them, and resist the urge to look for someone to blame when fate exacts the highest of prices.