2.  Case study  Factors – short and long term  Referral to Coroner  Post mortem  Purpose of Inquiry  Outcome  Recommendations

3.  Single motor vehicle crash  Driver failed to take a bend on a rural road  Vehicle has left the road and impacted with a tree  Driver died at the scene after sustaining multiple traumatic injuries  These injuries make it difficult for the Police to confirm identity  The matter is reported to the Duty Coroner by Police attending the scene

5. Key factors to be considered at early stage of the event:  Does a post mortem need to be directed?  Are there any cultural considerations?  Do the family want to view the deceased?  Can the driver be identified?

6. The evidence that will assist the Coroner as a result of the crash investigation: A.Driver  Speed  Alcohol/Drugs  Medical event  Distracted  Licensing issues

7. B.Vehicle  Mechanical fault C.Environment  Weather conditions  Road conditions Did any of these factors contribute?

8. D.Recommendations  Does the Coroner need to consider recommendations to prevent a similar death occurring in the future?

9. A fatal motor vehicle crash is reportable to the Coroner pursuant to section 13 (1) (a) of the Coroners Act 2006 : 13 Deaths that must be reported under section 14(2) Without known cause, suicide, or unnatural or violent (a) every death that appears to have been without known cause, or suicide, or unnatural or violent:death

10.  NIIO – National Initial Investigation Office  Receives all notifications of death  A Coroner is always on-call and available to discuss the death and provide directions

11.  Section 31 of the Coroners Act 2006, gives a Coroner discretion to authorise a post-mortem examination.  The matters specified in section 32 guide a Coroner in the exercise of this discretion  The extent to which the above concerns are taken into account is a matter for a Coroner’s discretion.

12. Section 32 criteria:  Will the post mortem disclose information that is not currently available?  Was the death unnatural or violent?  If the answer is “Yes”, was it due to the actions/inactions of other people?  Are there any allegations, suspicions or public concerns?  Likely prosecution by another organisation?

13. For this case study the Coroner will need to consider factors in relation to the MVC before making a final decision. The following two slides outline these considerations-

14. What factors need to be considered by the Coroner? Will the post mortem assist with: Identification Causes and circumstances of death Accident investigation Possible Prosecution

15.  Is there sufficient information available without post mortem?  Will a post mortem cause distress to family?  Are there cultural or religious grounds against a post mortem?

16.  Immediate family have right to object in some circumstances  Objection must be balanced against right of state to know with certainty causes and circumstances of death  Discussion and negotiation with family and other stakeholders (this may lead to lesser PM)  No objection does not obviate duty on Coroner to consider necessary criteria

17. Section 57 of the Coroners Act 2006 – Purpose of inquiries: 1.To establish:  that a person has died  the person’s identity  where and when the person died  the cause and circumstances of death 2. To make specified recommendations or comments to reduce the chances of a similar death

18. 3. To determine whether it would serve in the public interest for the death to be investigated by other authorities and if so, then referral to those agencies.

19.  NZ Police – Serious Crash Unit are the main investigating agency for MVC incidents.  SCU provide a report to the Coroner which forms the basis of the evidence for the inquiry  SCU have specialised knowledge and skills to deal with these investigations

20. At the conclusion of an Inquiry, the Coroner will complete a written finding that outlines the circumstances of the death and highlights any contributing factors. For this case study we will look at some of the possible recommendations that may have been applicable.

21. Driver factors: (Distracted driver)  Support for, and increase in public education campaign in respect of the dangers of driving while distracted, including the use of cell phones, texting and general tiredness Ministry of Transport

22. Vehicle factors: (Vehicle fault)  That the Agency bring to the attention of Warrant of Fitness inspectors, the risk that current WOF testing does not ensure headlights are providing sufficient illumination to reach the distance required by law New Zealand Transport Agency

23. Environment: (Lack of signage)  To improve signage by installing curve advisory signs and chevron boards for the approach to the bend ◦ New Zealand Transport Authority  District Council  Local council

24. Safer Journeys is New Zealand’s road strategy to 2020. The strategy:  Supports and reinforces the Coroners’ mandate to inquire into causes and circumstances of deaths  Coroners are important partners in creating a safer road system in a number of ways:

25.  Ensuring that inquiries take a whole of system approach (roads and roadsides, vehicles, speeds, use).  Providing early warning of emerging road safety issues.  Identifying opportunities for road safety partners to work collaboratively to address emerging issues  Providing a balanced public commentary on road safety issues which will help shape the road safety conversation in the media