Major changes to police pursuit policy are needed following a police chase that preceded a fatal crash near Whangarei, a coroner's report says.

The recommendation is part of Northland Coroner Max Atkins' finding, issued today, into the death Auckland woman Erin Jane Burgess, 18, who died on May 13.

Miss Burgess died from multiple injuries including severe head injuries after the car she was driving was hit by motorcyclist Kuran William Brunton, 29, 10km south of Whangarei on the night of May 12.


Police initially claimed after the accident that they had abandoned their pursuit of Brunton, which reached speeds of up to 190kmph. But the inquest heard that this was not strictly true -- a police car with sirens and flashing lights operating had followed Brunton right up to the time he crashed.

Mr Atkins found that the primary cause of Miss Burgess' death was the grossly careless and dangerous driving of Brunton who was being chased by police at high speeds before the accident.

After the accident, blood tests found that Brunton had consumed methamphetamine and marijuana.

However Mr Atkins was also critical of the way police handled the pursuit highlighting serious communication failures between the officers carrying out the chase and the police Northern Communications Centre.

His recommendations include:

* Orders to abandon a chase should be obeyed immediately and any questioning of reasons for the order should be left until later;

* Police should undertake regular training and refresher courses so that officers understand the mandatory requirements of the pursuit policy and the reasoning behind it;

* Once a pursuit is abandoned officers should not start a new pursuit;


* Supervisors should strictly supervise officers involved in high speed pursuits.

Mr Atkins said that poor communication and failure by police officers to immediately and completely carry out their obligations during the pursuit of Brunton meant that the strict supervision failed.

"It is tragic that it has taken such a terrible accident to clarify the need for total compliance with the policy, by supervisors, dispatchers and all police units involved," he said.

Police deputy commissioner operations Steve Long said today police would closely consider Mr Atkin's recommendations regarding Miss Burgess' death in a review of its pursuits policy.

"Police acknowledge the ongoing pain and grief experienced by the Burgess family over the death of Erin," Mr Long said in a statement.

"While there is little we can do to heal the loss they have experienced through the grossly careless and dangerous actions of Kuran Brunton, we will do our utmost to minimise the likelihood of similar deaths."

Mr Long said a team was nearing completion of the new policy, which would be finalised by the police board of commissioners early next year.

In the meantime a directive would be issued to officers reinforcing that communications centres were to control pursuits and that any order to abandon a pursuit should be followed immediately.

Mr Long said there were some differences between the police's initial report, which largely exonerated police, and that of the coroner and a supplementary report would be forwarded to the Police Complaints Authority (PCA) for review.

The PCA investigates all police chases in which a death occurs.

"The original report by Detective Superintendent Shortland looked at issues of compliance and culpability and found no criminal or disciplinary liability," Mr Long said.

"The coroner with his terms of reference relating to the time, place, causes and circumstances of how Erin Burgess died, took a holistic approach and found elements of the police pursuit system wanting. Of that we are in agreement."