Hutchison Paul: Coroners Bill — In Committee 
Hutchison Paul: Coroners Bill — In Committee 
[Volume:633;Page:4673] 
Dr PAUL HUTCHISON (National—Port Waikato) 
: 
 Thank you Madam Chair for the opportunity to speak on Part 3 of the Coroners Bill which deals with inquiries into causes and circumstances of deaths. I particularly want to confine my remarks to clause 73 which allows specialist advisers to sit with and help coroners. Clause 73(1) states: “If satisfied that it is desirable to do so the chief coroner may on the recommendation of a coroner appoint a cultural legal medical or other specialist adviser to sit with and help the coroner at an inquest by giving advice.” I am particularly interested in this area because of the situation of perinatal and maternal mortality but as well as that of course it includes child and youth mortality. 
My interest stems from the fact that during the 1990s the perinatal mortality committee ceased and it took something like 6 to 7 years before the Labour Government managed to get an effective Perinatal and Maternal Mortality Review Committee working in this country again. This is particularly serious given the circumstances relating to perinatal deaths and of course more recently to infant deaths and deaths of young children given the fact that we are at present confronting the tragedy of the Kahui twins. I think most New Zealanders would want to know that when the coronial investigation into their deaths occurs it takes place with the very best advice possible. 
There is no doubt that clause 73 which allows specialist advisers to sit with and help coroners is highly relevant. Professor Taylor from Dunedin who is the chair of the Child and Youth Mortality Review Committee was anxious that people are aware that this committee—which is a statutory committee set up under the Health and Disability Commissioner Act 2001—reviews and reports to the Ministers on the deaths of people aged between 4 weeks and 24 years. This is with a view to reducing the number of deaths in this group and to allowing continuous quality improvement through the ongoing promotion of quality assurance programmes. One would hope that if in the case for instance of the Kahui twins there is expert advice on every aspect from their leaving the hospital to when the tragedy occurred good data will be available from a medical and scientific viewpoint to ensure that the lessons that can be learnt are indeed well recorded and fed back to the various caregivers whether they be health workers social workers or whoever they are. In this way in the future when high-risk babies leave hospital everything possible will be done to anticipate and to help prevent avoidable tragedies as happened in that particular case. 
Professor Taylor certainly believes the committee would like to ensure that good epidemiological advice and data are collected on each occasion. We have come through almost two decades since the late 1980s of not having good data in this very crucial area so it is pleasing indeed to see clause 73. Clause 73(2) states: “The coroner’s recommendation that a specialist adviser be appointed must be made after having regard to any relevant practice notes issued … by the chief coroner.” and subclause (5) states: “Advice given by a specialist adviser may be given any weight the coroner thinks fit.” 
What is so poignant at the present time is that we know that risk identification has become quite a clear evidence-based practice but we have this gap after people leave hospital during their early years of life when at times there is not good continuous care and treatment. One of the problems that has come up recently is that district health boards are not allowed to give information for instance on births to Plunket. The lead maternity carers may know about a child being born but Plunket is not aware unless it is told specifically. It seems in many respects that the information restrictions due to the privacy code have absolutely gone berserk. In this simple sort of area it is vital that the Government takes notice and ensures we have good information flow to all the relevant people—relevant in terms of the case before us of the Kahui twins and relevant in terms of coronial inquiries. We need to ensure that the data collection is as good as possible. 
One of the other things that the Child and Youth Mortality Review Committee believes is important is a specific requirement for information collected for coroners by police or health-trained investigators to be directly passed to the mortality review committees. There is absolutely no doubt that this is one of the things the Minister if he is interested in improving the situation should ensure—although it is difficult to put in the legislation—is actually made mention of and that is why I am doing so today. 
Another point that Professor Taylor makes is that there needs to be a much closer link between coronial systems and relevant health investigation management and that of course is patently clear in the tragedy we have seen recently. 
His final point related to clause 61 where there is a potential restriction for researchers publishing on the topic of suicide. The view again is that this can be done anonymously that data collection is extremely important if we are to learn from the mistakes. Once again the underlying principle is actually there if the coroner gives permission for researchers and other people like them who are interested in quality assurance and quality improvement to gather data. The important point is to make sure there are not unnecessary hurdles in the way and that collecting good scientific-based evidence will act synergistically with an improved coronial bill to ensure that where there are preventable problems they indeed can be improved.