In the past few weeks coroners have been in the news. The investigations of the disappearance of an emotionally distraught woman at Piha, the Kahui twins murders and the death of a cyclist on Tamaki Drive have seen a surprising, some would say unusual, level of coroner opinion voiced on sensitive issues, some of which verges on editorializing.

For example, in the Piha case the coroner placed some responsibility for the young woman’s death on a couple of good Samaritans who tried to shelter and comfort her for four hours after she asked them not to call the police because she feared that the cops were angry at her. The coroner ignored the actions of seven other people who also interacted with the victim, including those who last saw her alive–naked and delirious talking to a light post–but did nothing and those at the house that she had fled from fearing sexual assault. He also downplayed the gross negligence of the police, who called a taxi rather than send a patrol car in response to the original 111 call from the distressed woman (the taxi driver was clueless and went to Onehunga rather than Piha). The coroner’s bottom line is that civilians should leave the handling of emergencies to professionals even if that means ignoring the wishes of those at risk. The implicit message could well be “do not get involved.”

The coroner in the Kahui twin case basically fingered the father for the murders. Since the father was acquitted of murder by a jury in a well-publicized trial, it will be interesting to see if the case is revived by the Police. The coroner’s verdict is clearly an instigation to do so.

The coroner in the Tamaki Drive cycle death case has suggested that it be mandatory for cyclists to wear high visibility clothing and to ride in cycle lanes where available. However, the cyclist was killed in daylight after swerving to avoid an abruptly opened door from a car parked immediately at the end of an irregularly marked cycle lane, on a notoriously tight corner. He ignored suggestions by bicycle advocates that the Auckland Council’s failure to remove parking along narrow stretches of Tamaki Drive contributed to the accident (which it did two days after the accident), or that the truck that killed her failed to adhere to the 2 meter gap rule (which ostensibly is the distance that should be maintained between cyclists and motor vehicles on roadways and which is in the road code). He reiterated a juries’ verdict that the motorist who opened the door without first looking behind him was not at fault. In effect, he blamed the cyclist for her own death.

I am curious about this. I am not an expert on Coroner’s courts or investigations, but I had thought that they were focused on the facts of the case in order to determine causality via a chain of events or circumstances. In this cases outlined above, the scope appears to have been expanded into opinionating and assigning blame rather than simply recommending improvements and safeguards to avoid similar occurrences. Have I got this understanding wrong or is this unusual?

I must confess that I live near Piha and have some local insight into the circumstances of the young woman’s disappearance. I am also a former recreational, commuter and competitive cyclist who has ridden on numerous occasions on Tamaki Drive (too flat for serious training unless it is a time trial, and only “safe” on early weekend mornings). I do not much care for infanticide regardless of who does it. So perhaps I am reading too much into these coroner’s reports, but from what I have seen it appears that in these cases they were interested in more than establishing the facts of the matter at hand.