Role of the National Duty Coroner (2014/1)

1 Introduction

1.1 This practice note replaces the NIIO practice note 2013/1.

1.2  The purpose of this practice note is three-fold: to clarify the role and expectations of the Day-time National Duty Coroner (“DNDC”), to clarify the role and expectations of the After-hours National Duty Coroner (“ANDC”), and to set out the most effective means of working with the National Initial Investigation Office (“NIIO”).

1.3 This practice note has been prepared following the transition to NIIO operating 24 hours per day (24/7) and more latterly the transfer of responsibility for transportation from Police to the Ministry of justice.  NIIO staff are responsible for providing all administrative support to Coroners, from the reporting of deaths up to the release of bodies and providing written notification to the family (Letter 1).

1.4 This practice note is prepared in order to promote consistency of practice amongst Coroners in terms of the extent to which deaths are responded to and to develop consistency of practice amongst Coroners in terms of how they work with NIIO staff. It also clarifies what the DNDC and the ANDC may expect in terms of the extent and nature of communication from NIIO staff.

2 The role of the National Duty Coroner

2.1 The rostered DNDC will be the National Duty Coroner between 8am to 5pm from Monday to Friday each week. The rostered ANDC will be the National Duty Coroner at all other times.

2.2 It is the responsibility of the DNDC and the ANDC to provide a timely response to deaths referred to her/him, and, subject to paragraph 5 below, to progress files to the greatest extent possible on the information available (see Note 1).
Note 1: It is expected that the ANDC will advance routine deaths, as well as urgent matters, in the interests of providing a seamless and efficient service for families.

2.3 Notwithstanding paragraph 2.2, it is expected that the ANDC will assess whether progressing routine matters is prudent in all the circumstances (see Note 2), or whether the matter should more appropriately be referred to the DNDC to progress.
Note 2: Circumstances to be considered include the time of death and appropriateness of contacting families outside of business hours, time to elapse until 8.00am the next business day, tiredness/capacity of ANDC.

2.4 In discharge of these responsibilities the ANDC / DNDC will make directions via email for NIIO staff to action to obtain information necessary to progress the file to either an order to perform a post mortem examination or an order for release of the body.

2.5 National Duty Coroners are required to maintain a contemporaneous legible record of conversations and actions handled by them and furnish them promptly to NIIO. 

2.6 The ANDC and the DNDC should discuss any issues which arise at handover as the need arises. One NIIO coordinator will also be available to liaise with the duty Coroner at the start of each shift to discuss the Overview and where the priorities lie. Otherwise it is expected that the Overview, as prepared and maintained by NIIO staff will be sufficient to inform the ANDC / DNDC of matters currently being dealt with.

2.7 No formal arrangements will be made to provide for rostering a back-up either for the ANDC or the DNDC. It is expected that on the rare occasion that a back-up may be needed, all Coroners will endeavour to assist when called upon by the Judicial Support Manager.

3 Communication Between the DNDC / ANDC and  NIIO Staff

3.1 NIIO staff will advise the DNDC / ANDC of all deaths as they are notified to NIIO, and will briefly summarise the nature of the death and circumstances as known. In the cases where Police are locating a doctor, NIIO staff will inform the DNDC / ANDC of that fact and if the doctor has been located whether the doctor is willing to sign an HP 4720. If the doctor signs an HP 4720 NIIO staff will enter the information into CMS as an Advice case to ensure that case figures accurately reflect the number of notifications received. If a Doctor has yet to be contacted this is also to be notified to the National Duty Coroner.

3.2 The DNDC will be sent an Overview of the status of all cases at 8:00am every day and as requested. A NIIO coordinator will be available to discuss the Overview with the DNDC.

3.3 The ANDC will be sent an Overview of the status of all cases at 5:30pm and 6:00am every day and as requested. 

3.4 The ANDC will advise NIIO of the preferred means of contact (ie phone call, text message, or email, at the start of each period on duty, and will also advise of any change to immediate availability due to personal circumstances.  Fax as a form of communication is not a preferred method but may be necessary as a back-up.

3.5 The Coroners Court is a Court of record. Accordingly, best practice dictates that NIIO staff will email documents to the DNDC / ANDC, using only the Ministry of Justice (“MOJ”) e-mail system. The initial email in respect of a death will include a scanned copy of any handover email or Memorandum, the initial notification, a copy of the documents sent by police, and a copy of file notes/memoranda of all conversations and other actions taken by them in respect of the death.

3.6 MOJ email through MOJ encrypted hardware is the agreed means of communication as it results in a confidential, legible, chronological record of matters considered, directions given and actions taken. If the DNDC / ANDC is not able to use email, then faxes may be used, but NIIO staff and the DNDC / ANDC must ensure all hand written notes/directions are legible and that the date and time of the note/direction is recorded on the note/direction.

3.7 If a situation is of such complexity or urgency that verbal directions are sought or given, NIIO staff and the DNDC / ANDC must follow up with an emailed or faxed typed or legibly written file note, so that there is a clear chronological record of actions taken, matters considered, and directions given.

3.8 Unless otherwise directed by the Chief Coroner, NIIO staff will deal with all reportable deaths from the time of notification of a death until the body has been released and the Letter 1 has been sent to Family Representatives. In most cases it is anticipated that this will occur within the first 48 hours of the receipt of a report of a death.

3.9 When a file is completed and referred to the region, NIIO staff must ensure that the file on transfer constitutes a complete chronological record of every action taken on the file, and includes all documents received by NIIO in respect of the death. The Coroner is entitled to expect that a file opened by NIIO includes evidence of: all conversations in respect of a death; all actions taken in respect of the death (for example, calls made that were not answered); all matters considered in respect of a death; and all directions made including timings. The Coroner should not be in a position of having to ask the DNDC / ANDC why any given step was taken; the file on handover should contain all such information.

4 Objections to Post Mortem

4.1 The ANDC should wherever possible, deal with objections to post mortem raised pursuant to section 34 of the Coroners Act 2006. Where the ANDC considers that a post mortem is necessary, and the family confirm an objection to post mortem, the matter may be referred by the ANDC to the DNDC to action.

4.2 It is not the role of NIIO staff to justify the DNDC / ANDC’s view regarding a post mortem. NIIO staff can be expected to convey the NDC’s view and the reasons for it to the family, but should not be asked to enter into a discussion or negotiation justifying that view.

4.3 In the event the family indicates it objects to post mortem NIIO staff should try to obtain the reasons for the objection in writing, and advise the family they will get back to them with a timetable for progression of the matter after speaking with the DNDC / ANDC. In most cases it is anticipated that a decision on an objection will be made by a NDC within 24 hours of receipt in writing of the reasons for the objection.

5 Availability

5.1 The DNDC / ANDC should be available to NIIO staff at all times while on duty, and should respond to a call or text message from NIIO staff within 30 minutes of it having been left. If the DNDC / ANDC cannot meet the 30 minute call back deadline s/he must advise NIIO in advance of the period during which s/he will not be available. This includes when the ANDC is retiring for the evening.

5.2 Even when the DNDC / ANDC has advised s/he is unavailable, it is expected that NIIO staff will contact her/him in the following situations:

  • To respond to requests for an immediate post mortem  (including homicides) that cannot appropriately wait until the DNDC / ANDC is available;
    To speak to doctors who require an urgent decision about jurisdiction that cannot properly wait until the DNDC / ANDC is available, provided that NIIO staff should advise callers that they must, except in special circumstances, first send a legible completed Hospital Notification form of a type from time to time approved by the Chief Coroner with a direct dial or cellphone number for the doctor who wishes to speak to the Coroner, and that desirably the  Doctor has discussed the case with his or her Consultant, is fully informed and able to explain in detail the background circumstances with confidence.
  • To speak to doctors about matters such as organ donation that cannot properly wait until the DNDC / ANDC is available.
  • To deal with deaths of such national significance that they require immediate attention by the DNDC / ANDC.
  • Authorising viewing of bodies, bodies staying with family and transportation of bodies.
  • To seek direction from the DNDC / ANDC in situations where the on duty Senior NIIO staff member is of the opinion that an immediate discussion with the DNDC / ANDC is necessary.

5.3 Each day the DNDC may nominate an hour during the day when the DNDC will take a lunch break taking his/her MOJ funded cellphone and shall advise NIIO staff of the time nominated. During the lunch break NIIO staff will not contact the DNDC except for urgent matters as set out in paragraph 5.2. It is preferable that a lunch break not be taken during the busy period in the afternoon when preliminary post mortem reports become available to NIIO. This is to be avoided where possible.

5.4 The ANDC may nominate two meal breaks on Saturday and two meal breaks on Sunday of one hour each and shall advise NIIO staff of the time nominated. During the meal breaks NIIO staff will not contact the ANDC except for urgent matters as set out in paragraph 5.2.

6. Workplace During Rostered Duty

6.1 The DNDC shall operate from the chambers provided by the MOJ. This may be the chambers provided at the respective rostered Coroners’ regional base (regional chambers) or may, with the approval of the Chief Coroner, be the chambers situated at NIIO in Ellerslie, Auckland (NIIO chambers).

6.2 The ANDC shall operate from the respective rostered Coroners’ home office or from chambers provided by MOJ. This may be the regional chambers or may, with approval of the Chief Coroner, be the NIIO chambers.

6.3 When the ANDC / DNDC is operating from the NIIO chambers the ANDC / DNDC may claim reasonable and actual expenses and any other allowance that may be claimable for performing the functions of the ANDC.

6.4 It is acknowledged that the Auckland resident Coroners are not able to claim reasonable and actual expenses for operating from the NIIO chambers as the NIIO chambers is within their base region unless agreed in advance by the Chief Coroner.

7.  Documentation

7.1 Unless an electronic signature is used, the original signed copies of key documentation (such as Cor 1, Cor 3, Cor 11, Cor 13, T3 and HROD) shall be promptly, after completion of a duty period, passed to the Coroner’s Case Manager or Office Administrator for sending promptly to the Case Manager for the Coroner to whom the matter has been assigned.

8. Post-Mortems

8.1 Some mortuaries will, from time to time, experience heavy workloads to the point where the available pathologist may not be able to complete all post-mortems scheduled for that day.  As a result, some post-mortems are held over and performed the following day.  This is most likely to occur on Mondays or following public holidays, where post mortems are not routinely performed over that time. This problem has occurred in Hamilton and Palmerston North mortuaries in particular.

8.2 To avoid the situation where post-mortems have to be held over to the following day, NIIO staff will monitor the number of pending post-mortems for mortuaries (particularly regional mortuaries) over the weekend of public holidays and will advise the Duty Coroner at the earliest opportunity when it appears that the number scheduled for a particular mortuary is likely to exceed capacity.

8.3 The Duty Coroner will then consider the desirability of directing immediate post-mortems to be performed over the weekend or public holiday.  The Duty Coroner (Or NIIO staff) should contact the duty pathologist for the affected mortuary and discuss the situation, and take into account the view of that pathologist and immediate family before the Duty Coroner directs an immediate post-mortem.

8.4 If it is not possible or practicable for an immediate post-mortem to be performed then the Duty Coroner shall consider, and indicate to NIIO staff, which post-mortem(s) should be held over until the following day. This may also require discussion with the duty pathologist.  NIIO staff will then notify the family of the deceased that the post-mortem will have to be delayed.

8.5 The Duty Coroner should also consider whether it is practicable to re-distribute some of the post-mortems to another mortuary.

Judge Neil Maclean
Chief Coroner
Date: 24 July 2014

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