Post on 17-Dec-2015
Road Traffic Incident Management
Seminar
Coroner Gordon Matenga17-18th March 2014
Contents
Case studyFactors – short and long termReferral to CoronerPost mortemPurpose of InquiryOutcomeRecommendations
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
Case Study – Fatal MVC
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?
Factors/Issues - Immediate
The evidence that will assist the Coroner as a result of the crash investigation:
A. Driver Speed Alcohol/Drugs Medical event Distracted Licensing issues
Factors/Issues – Long term
B. Vehicle Mechanical fault
C. Environment Weather conditions Road conditions
Did any of these factors contribute?
Factors/Issues – Long term
D. Recommendations
Does the Coroner need to consider recommendations to prevent a similar death occurring in the future?
Factors/Issues – Long term
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:
Referral to the Coroner
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
NIIO 24/7
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.
Is a post mortem required?
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?
Is a post mortem required?
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-
Is a post mortem required?
What factors need to be considered by the Coroner? Will the post mortem assist with:
IdentificationCauses and circumstances of deathAccident investigationPossible Prosecution
Factors supporting a PM
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?
Factors against a PM
Objection to post mortem
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
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
Purpose of Inquiry
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.
Purpose of Inquiry
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
Crash Investigation
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.
Outcome
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
Recommendations
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
Recommendations
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
Recommendations
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:
Safer Journeys for Coroners
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
Safer Journeys for Coroners