Coronial inquiry process may deepen trauma

Many bereaved Māori families feel excluded from coronial investigations, struggle to understand what is happening and wait years for answers after the suicide of a loved one, a new study has found.

The study examined whānau experiences of coronial services following the suspected suicide of a rangatahi as well as coroners’ perspectives on their engagement with whānau. A team including University of Auckland Professor Antonia Lyons conducted the research.

Whānau described legal jargon, unanswered phone calls and processes they felt added to their distress.

"They told us the system isn't working very well for families, and it's particularly not working well for Māori families," Lyons says.

Part of a coroner's role is to help prevent future deaths, she says.

The project was driven by personal experience as well as professional concern, says lead researcher Clive Aspin (Ngāti Maru, Ngāti Whanaunga, Ngāti Tamaterā), an adjunct associate professor at Victoria University of Wellington.

Aspin keeps a sheet of paper bearing the names of 12 people he has known who died by suicide, including friends, colleagues and acquaintances.

"Just about everyone I speak to says they know somebody who has died by suicide," he says.

"Young Māori people have some of the highest rates of suicide in the world.”

The research included interviews with 11 Māori whānau who lost a rangatahi to suicide and later had to navigate the coronial system.

Many families wanted a greater role in helping coroners understand why their loved one died.

"They hardly ever get involved in the process of trying to understand why the person died," Aspin says.

Some whānau waited four or five years for a coronial finding.

Others described opening their letterbox years after their loss to find a report detailing the circumstances of their child's death, without warning or support.

Many whānau told researchers they felt tikanga and Māori approaches to death and grieving were not adequately recognised during the coronial process. Families also reported that official procedures sometimes took priority over cultural practices and the opportunity to be with their loved one after death.

"The system can be improved by respectfully engaging with whānau and providing them with the support they need at times of trauma," Aspin says.

Researchers also interviewed 12 coroners across New Zealand, who described heavy workloads, significant backlogs and legal requirements that made meaningful engagement with families difficult, Lyons says.

“Coronial services need to be better resourced, more trauma-informed and more culturally responsive.

"These people are doing enormous amounts of important work, and this is made even more challenging by the kind of backlogs they have and the pressures they're under.”

• Read the study