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On these pages, you'll find information about the 15 March 2019 Christchurch Masjidain Attack Coronial Inquiry, and how the coronial process works.
The Christchurch Masjidain Attack Coronial Inquiry
First Phase Coronial Inquest Hearing
Helpful infographics can be viewed here.
The same infographics in Arabic, Bengali, Dari, Hindi, Pashto, Somali, Turkish and Urdu can be viewed here.
A timeline of the Coronial Inquiry can be viewed here.
The Christchurch Masjidain Attack Coronial Inquiry
The Coronial Inquiry into the Christchurch Masjidain Attack is the largest coronial investigation New Zealand has seen and is nationally and internationally significant.
In New Zealand, a Coronial Inquiry is a collaborative process to establish the truth of what occurred, with a view to making findings and recommendations to prevent deaths in similar circumstances in the future. It cannot impose penalties or award compensation.
This Coronial Inquiry follows criminal proceedings and a Royal Commission of Inquiry. The Royal Commission, in particular, was considered closely in setting the scope of the Coronial Inquiry.
There are more than 140 Interested Parties in this Coronial Inquiry. Many of these Interested Parties are the immediate whānau (family) of each of the 51 people who lost their lives in the terrorist attack. Under the Coroners Act 2006, immediate whānau hold Interested Party status as of right. The remaining Interested Parties have sought and been granted Interested Party status by the Coroner.
Access to information has been a key consideration. The 51 people who lost their lives came from 21 countries and spoke 13 different languages. A range of additional measures have been taken to ensure the immediate whānau are fully supported and enabled to participate.
This includes Legal Aid-funded lawyers, translated content, cultural advice, court victim advisors, and taking a trauma-informed approach throughout the coronial process, particularly in regard to informed choices about viewing sensitive material disclosed to Interested Parties.
The First Phase Inquest hearing will be supported by an online stream available to registered attendees to ensure families of those who lost their lives can attend, both in New Zealand and overseas.
The role of a Coroner
Coroners are like judges. They are qualified lawyers appointed as judicial officers to investigate unexpected, violent or suspicious deaths to find out what happened.
Coroners look at and decide the facts about certain things to do with a person’s death, including:
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that a person has died
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who the person was
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when and where the person died
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how the person died
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the circumstances around the death.
A coroner may:
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start an inquiry to investigate a death, and to find out the cause and circumstances of that death; and
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make recommendations and comments that may help to prevent similar deaths in the future.
A coronial inquiry is a process to find out the facts of a death. A coronial inquiry does not decide who is guilty of causing a death.
If a coroner believes they need more evidence to find out the facts of a death, they can hold a hearing in court. This is called a coronial inquest. At a coronial inquest, a coroner will hear from witnesses and consider evidence.
A coroner cannot start an inquiry to decide on civil, criminal, or disciplinary liability.
The powers that a coroner has are defined under New Zealand law, in the Coroners Act 2006.
For more information, see: Coroners Act 2006(external link)(external link)
The Coronial Process
Investigation
This coronial process commenced on 15 March 2019, but was put on hold while the criminal proceedings and the Royal Commission of Inquiry were completed. The offender was sentenced in August 2020 and the Royal Commission reported back in November 2020.
The coronial process recommenced on 14 December 2020, when the Chief Coroner wrote to the whānau of those who lost their lives in the attack.
Inquiry
In October 2021 the Chief Coroner, who was then Judge Deborah Marshall, opened an inquiry into each of the deaths of the 51 people who lost their lives in the attack.
Judge Marshall also invited submissions from families and Interested Parties on the proposed scope of the Inquiry. Coroner Brigitte Windley took over the Inquiry from 23 November 2021, when Judge Marshall retired. Coroner Windley was appointed Deputy Chief Coroner in July 2023.
The scope stage of the Inquiry has been completed. The Inquiry is now in the substantive stage.
Scope of the Inquiry
Coroner Windley heard submissions on the scope of the Inquiry from the whānau of those that died and other Interested Parties. As well as considering their questions and concerns, the Coroner also considered what issues had not been resolved by the criminal prosecution and the Royal Commission of Inquiry.
Coroner Windley issued her scope decision on 28 April 2022, identifying 12 issues to be examined further. The Coroner’s scope decision is available here(external link). A further issue - the operation of an emergency exit door in the prayer room at Masjid an-Nur was added later.
An aide to that decision is available here(external link).
Substantive Inquiry
During the Substantive Inquiry, the Coroner identifies and provides Interested Parties with further evidence about each issue, and determines what, if any, further investigation and evidence is needed.
A substantial amount of documentary and digital evidence has been gathered and assessed for relevance and sensitivity during this Inquiry. Relevant evidence is disclosed to Interested Parties through their lawyers, or on request if they do not have one. Specific measures are in place for the disclosure of sensitive evidence, and the wellbeing of those who choose to access it.
The information provided to Interested Parties in this Inquiry cannot be shared further and is subject to non-publication orders under section 74 of the Coroners Act 2006, due to the sensitive nature of the material.
First Phase Coronial Inquest Hearing
The First Phase Inquest hearing is part of the Substantive Inquiry. The First Phase Coronial Inquest will examine ten issues, all relating to the day of the attack:
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The events of 15 March 2019 starting from the commencement of the attack through to the completion of the emergency response and Mr Tarrant’s formal interview by Police.
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The response times and entry processes of Police and ambulance officers at each mosque
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The triage and medical response at each mosque
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The steps that were taken to apprehend the offender
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The role of, and processes undertaken by, Christchurch Hospital in responding to the attack
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Co-ordination between emergency services and first responders
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Did Mr Tarrant have direct assistance from any other person on 15 March 2019
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If raised by immediate family, and to the extent it can be ascertained, the final movements and time of death for each of the deceased
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(a) the cause(s) of death for each deceased
(b) whether any death could have been averted had alternative medical triage and/or medical treatment been administered having regard to the context of the attack.
13. whether Masjid an-Nur's emergency exit door in the south-east corner of the main prayer room failed to function on 15 March 2019 to allow egress in the course of the attack, and if so, why?
The First Phase Coronial Inquest on these 10 issues was held at the Christchurch Law Courts between 24 October and 15 December 2023.
Issue 13 was adjourned part-heard in the First Phase hearing, with further evidence heard in May and August 2024.
Second Phase hearing on Issue 10
The Second Phase of the Inquiry included a hearing of evidence on Issue 10 from 8-24 October 2024. Issue 10 addressed the following matters:
- Insofar as the specific licencing process as it was applied to Mr Tarrant in 2017, whether there were any operative errors, failures, or deficiencies with respect to the “fit and proper person” assessment made by Police, other than those identified by the Commission?
- Whether in 2017 the Police could, and should under the firearms licencing guidance and policies that applied, have asked Mr Tarrant and his referees questions designed to elicit information as to whether he held extremist political, racist or any other beliefs or views?
- On the basis of the licensing process that was undertaken, and information Police had gathered in the course of that process, should Mr Tarrant have been assessed as a ‘fit and proper person’ and granted a firearms licence?
- Accepting, as the Commission did, that as a firearms licence holder Mr Tarrant lawfully obtained firearms, magazines, and ammunition that were used in the attack:
- How (if at all) did the military-style semi-automatic firearm (MSSA) loophole or gap materially facilitate, or otherwise contribute to the attack and deaths in a more than negligible way?
- Was the MSSA loophole or gap capable of being addressed prior to the attack by means other than legislative reform?
- On a counterfactual analysis, on the balance of probabilities would the following (individually or collectively) have made a material difference to the licencing decision, and/or ultimately to the commission or nature of the attack, or the chances of survival for the 51:
- Had Police rejected Gaming Friend and/or Gaming Friend’s Parent as referees for Mr Tarrant’s firearms licence application?
- Had Police accepted Lauren Tarrant as a referee for Mr Tarrant’s firearms licence application?
- Had Police vetting practice or procedure directed questions of applicants and referees designed to elicit any extremist beliefs (of any kind) held by the applicant?
- Had the MSSA “loophole” or gap been closed prior to the attack (to the extent there were means to achieve this other than by legislative reform?)
- Whether subsequent legislative amendments, policy or process changes, or other initiatives, have addressed:
- the failures or deficiencies identified by the Commission or otherwise under (a) above; or
- the MSSA “loophole” or gap.
- Whether there are any comments or recommendations that may be made under s 57A in relation to the firearms licencing regime that may reduce the chances of further deaths in similar circumstances.
Issue 11 and 12
No decision has been made on whether an inquest hearing will be held on Issue 11 and 12. These issues are:
11. (a) Whether the offender’s online activity can be shown to have played a material role in his radicalisation with a particular focus on the period between 2014 and 2017
(b) If so, consideration will be given to examining the extent of monitoring of users for extremist content by the relevant platform(s), then and now.
12. The community's ability to detect and respond to the risk of violent extremism in others.
A decision whether any further inquests are necessary will be made as the substantive inquiry phase on these issues progresses.
Findings
The Coroner can release interim findings, but will release full and final findings following the conclusion of the Inquiry. Findings may include recommendations under Section 57 (3) of the Coroners Act 2006, aimed at preventing deaths in similar circumstances in the future.