More than eight years on from losing her son to suicide, Corinda Taylor says the intense pain is yet to subside as she still waits for the coronial inquest into his death to be completed.
As the delay in pinpointing critical factors around the lead up to his death continues, she is now fighting for changes within the coronial system so other families don't have to face lengthy waits, as she has.
Taylor is calling for the "urgent need" for more coroners to reduce the years-long delays, and access to free legal representation and medical experts for whānau during the inquest process, and more support for loved ones bereaved.
She says long, uncertain waits add pressure to many who are already struggling to cope.
"I think they are just so overworked," she told Newshub. "It's a national disgrace. This has to change. Our justice system needs to be fairer for those who suffer the trauma of suicide in their family."
Taylor founded and now manages the Dunedin-based Life Matters Suicide Prevention Trust after losing her 20-year-old, Ross, in 2013. She says the inquest process has caused a lot of extra trauma for her, and can significantly impact families trying to accept a loss when the process is drawn out.
She recently conducted a survey among suicide-bereaved families which found 38 percent faced waiting times between three to eight years for their inquest to be completed.
In some cases, loved ones gave up.
"That is how the truth remains buried," Taylor says.
'Number in a queue'
The reported average time for coronial cases to be completed in the year to 31 March 2021 was 484 days. This was up from 351 days the previous year, and 303 days five years earlier.
Ministry of Justice data shows around 50 percent of cases before the Coroner were more than 12 months old at the end of 2020, compared with 30 percent in 2014.
Since Taylor's son died, she says she's been living in limbo during an "extremely tough” journey trying to complete the steps required to get through the process.
The coroner will be notified if a death appears to have been unexpected, including in instances it is believed to be self-inflicted, unnatural, violent or during childbirth.
About 5,700 deaths are reported to coroners every year; of these, coroners accept jurisdiction for around 3,600.
These investigations are important for informing coroners’ recommendations to be helpful in preventing any deaths from occurring in similar circumstances.
A full or partial post-mortem is carried out which families are usually involved with and at some point they will hear from a coronial case manager.
"Basically you get a number in a queue," Taylor says.
If the police or the Health and Disability Commissioner need to investigate the death, that will take priority.
Chief Coroner Judge Marshall told Newshub coronial inquiries will be put on hold pending the outcome of another agency’s investigation, acknowledging some inquiries not being completed until some time after a person has died.
Taylor and her husband's complaint to the Health and Disability Commissioner took four years to complete. The Otago University student had received treatment from Southern District Health Board's (SDHB) mental health services in 2012 and 2013.
A report by Mental Health Commissioner Kevin Allan in April 2017 ultimately found SDHB and a psychiatrist failed to provide services to Taylor with "reasonable care and skill", and to have breached the health and disability consumer rights code.
"We did want an inquest because we felt there were some issues that weren't addressed through the HDC process."
'Frightening and overwhelming'
Taylor’s coronial inquest process was launched four years ago, once the HDC released its findings. Taylor says this is when her experience became "complicated" and "traumatising".
"You go to court and you have a discussion about the scope of the hearing, have these discussions without any legal support, you don't understand the system. I feel like the system is stacked up against families because it's so complicated. You really have to have a legal degree."
Newshub asked Minster for Courts Aupito William Sio what support is currently available to families going through a coronial inquest.
"Legal Aid is government funding to pay for legal help for participants and families for coronial inquests. I can advise that inquests held by a Coroner are usually inquisitorial and informal."
A Ministry of Justice spokesperson said legal aid applications are considered on a case-by-case basis.
Minister Sio said legal representation at the inquests is usually at the discretion of the families or parties involved and it is not a requirement.
"Legal aid is available to help grieving families who wish to access legal assistance in coronial inquests."
But Taylor disagrees.
"Families need the same level of legal support as all the other parties in an inquest independently from the Coroner, especially when the suicide happened while the person received care from a state organisation," she says.
"DHBs, in particular, have the best legal teams representing them with families having none due to the costs."
Research conducted by Taylor indicates 89 percent of respondents to her survey said they did not receive legal funding support.
Taylor explains it can be frightening and overwhelming for a family to face lawyers representing DHBs and psychiatrists.
"Families also need the same level of expert opinion support as the other parties independently from the Coroner. No family should be expected to cross-examine witnesses, go on the stand, and compete with expert lawyers who work daily in this field."
Taylor says she and many other families do not qualify for the free legal aid.
'It is hoped the overall workload pressure will be reduced'
Chief Coroner Judge Marshall told Newshub work has begun to address timeframes for the completion of coroners’ inquiries, and more initiatives are being planned to address the high number of deaths by natural causes that are referred to the coroner.
"Every death reported to the Coroner is different. Accordingly, coroners must consider evidence from a range of sources. In order to try and prevent similar deaths, coroners often consult with multiple agencies," she says.
"When the coronial bench is up to full strength for a sustained period of time (with 18 full-time coroners and 8 relief coroners) the length of time should reduce."
A Ministry of Justice representative said the number of coronial cases on hand does continue to rise, with coroners "typically receiving more cases than they close each year", and acknowledged there are "public concerns" with the length of time the coronial process can take.
"The Ministry continues to work alongside the Chief Coroner to identify opportunities to reduce the wait time for families and whānau. For example, the Ministry is considering whether there are opportunities to reduce the number of cases, particularly natural causes deaths, that enter the jurisdiction."
Minister for Courts Aupito William Sio told Newshub reducing the waiting time for families to receive closure via the coroner is a "key priority" and something that he is "focusing on for the rest of the term".
"Ministry of Justice officials advise me that they are exploring a number of initiatives including opportunities to prevent unnecessary referrals being made to the coroner. This is expected to impact the length of time taken to close cases requiring an inquiry, as well as to reduce the overall workload pressure."
He says at this time he has not asked the Ministry of Justice to review the 2006 law Taylor is petitioning to change.
"Inquests make up a small part of the Coronial workload. In 2020, the Government appointed an additional eight part-time relief coroners as well as several full-time coroners to fill existing vacancies. All relief coroners have been appointed to the bench as an additional resource to try and help with the workload.
"Through the appointment of the relief coroners and the Ministry’s initiatives, it is hoped the overall workload pressure will be reduced."
The Ministry of Justice says these relief coroners, alongside the permanent full-time coroners, take turns being rostered as the Duty Coroner.
"This means that permanent full-time coroners are now doing fewer Duty Coroner shifts and have more time to focus on progressing their individual caseload. The relief coroners also have commensurate caseloads of their own, so are expected to help to progress the overall coronial caseload."