WARNING: This story deals with suicide and may be upsetting.
Corinda Taylor waited almost 10 years for answers from a Coroner about mental health treatment her son Ross received leading up to his suicide.
But when the findings finally came in a 123-page decision in August, the Coroner made no recommendations to help reduce the chances of similar deaths in the future - one of the main reasons inquests are held.
This was despite an earlier critical report from the Health and Disability Commissioner [HDC] who found the former Southern District Health Board in breach of the code of patient rights for failing to appreciate the full picture of Ross' condition.
It also criticised the joint decision-making process around Ross' care along with psychiatrist Dr Richard Mullen for failing to make Ross aware of alternative treatments.
Taylor, who began the Life Matters Suicide Prevent Trust in the wake of her son's death in 2013, believes it's because she and Ross' father Sid did not have legal representation throughout the 10-day inquest held in the Dunedin District Court in 2020.
Lawyers are now commonplace at inquests but families of the deceased are the only party that does not get legal representation without paying for it.
Health providers, medical practitioners, police, and even the Coroner - to name a few - can have a lawyer act for them, usually paid for either by taxpayers or insurance.
Taylor said it's not a level playing field and can drastically affect the outcome of an inquest, which takes an inquisitorial approach as opposed to adversarial.
So today Taylor presented a submission to Parliament's Justice Committee on proposed changes under the Coroners Amendment Bill.
The bill aims to facilitate better access to justice for families interacting with the coronial system by making amendments to the Coroners Act 2006.
It also aims to reduce the distress caused to grieving families by reducing the time spent waiting for coronial findings.
Taylor's submission asks for:
• Free legal and expert witness support for families/whānau;
• All coroners to undergo training around inquisitorial processes and in grief and trauma;
• That suicide-bereaved families are eligible for ongoing, free counselling;
• And that hard paper copies of historic findings should be digitised.
She also wanted the lengthy delays addressed but did not believe the bill's addition of coronial associates would achieve that goal.
"Sid and I have since experienced the coronial system first hand," Taylor said.
"It is not something we would recommend to other families as the process was horrendous.
"Our son's life was completely ignored and it was a bitter battle with us against teams of lawyers.
"There was no compassion. It took more than nine years to get a report - almost two years after the 10-day inquest - from the Coroner who did not offer one recommendation despite a damning HDC report."
At the time of his findings on Ross' death, former Coroner David Robinson stressed his function as Coroner was not to find fault or reconsider those matters.
Taylor said after her youngest child's death at just 20, she and her husband were thrown into a coronial system that did not help them to heal.
Instead, Taylor described it as traumatising and dehumanising.
She said bereaved whānau involved in an inquest were expected to prepare their own submissions and cross-examination while at the same time grieving a significant loss, with most unable to afford legal experts and mental health support.
"As laypeople, we are not equipped to deal with complex legal arguments. It is simply not fair for the bereaved to be expected to do this, especially when no support is given and a
legalistic approach is taken by some coroners.
"Not having our own legal team prevents us from telling our story. The current system is not a safe place for grieving families."
In 2020/21, 607 people died by suicide, leaving thousands of bereaved whānau significantly affected every year with little support in place, Taylor said.
She is not the first suicide-bereaved mother to call for an overhaul of coronial services.
In 2018, Jane Stevens told the NZ Herald "everybody lawyered up" for an inquest into the death of her son Nicky Stevens by suicide in 2015.
Stevens and her husband Dave Macpherson initially spent $10,000 on a lawyer but abandoned that when a King's Counsel acted for them pro bono.
In that case Coroner Wallace Bain ruled Nicky's death was avoidable and found the then Waikato District Health Board wanting for allowing the 21-year-old out of mental health care on unescorted leave against the express direction of his parents.
Coronial services have been struggling to cope with demand since 2014.
About 5700 deaths are referred to coroners each year, with them accepting jurisdiction for around 3600.
In 2020/21 coroners closed 3321 cases with it taking on average 479 days to close a case, an increase of 97 days from the year prior.
There are currently 16 coroners in New Zealand with a cap of 20.
SUICIDE AND DEPRESSION
Where to get help:
: 0800 543 354 (available 24/7)
: 0508 828 865 (0508 TAUTOKO (available 24/7)
• Youth services: (06) 3555 906
: 0800 376 633
: 0800 942 8787 (11am to11pm)
: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111