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

Questions?