Ardern JacindaJACINDA ARDERN (Labour): I think Minister Adams is absolutely fair to reflect on the amount of work that has clearly gone into this bill. The select committee process was a place for robust debate and discussion. After that robust debate and discussion and our attempts at the Committee stage to make a number of amendments we have unfortunately had to make the decision that on balance there are elements of this bill that we simply cannot support.But there are elements—and I would include in that the purpose of the bill generally—that we do support. If we come back to the point at which the bill was first introduced it set out—as the commentary of the Justice and Electoral Committee states—that the primary aim of the bill is to seek to improve the timeliness and efficiency of the coronial system by amending the Coroner's Act 2006. I think that is a point that we could all agree on. At the moment there are significant delays in our coronial system. The Minister spoke today at the select committee Estimates hearing about the fact that there has been a 20 percent reduction in the time that these cases are taking but even then there is a significant backlog. During the course of this debate I met a family member of someone who is the subject of a coroner's case who had waited more than 1000 days. That is not unusual. That length of time is absolutely devastating if you are a family member waiting for closure of a case so when it comes to the substance of the purpose of this bill we certainly supported it.We would also use this opportunity to just state a few concerns. Although we want the backlog of coroner's cases to be dealt with we do have concerns that there has been talk of contracting out and bringing in external legal services in order to facilitate the processing of coroners' reports. Our worry with that is that it is a legislated function that a coroner holds and it does muddy the waters somewhat to be having external legal services processing those inquiries and inquests.If I could come to the areas where we still have concerns that we consider significant enough on balance to not support this bill the first—which we did not submit an amendment on but which did stand out to us—sits under new section 57A in clause 30. That sets out what a coroner is able to make recommendations around. This bill used the opportunity to narrow that function. The point that I would make is that if this bill was really about just trying to make the system more efficient it is not really at the point that a coroner is writing recommendations that we are seeing a lag in processing. The point at which a coroner is sitting down at a desk as it were perhaps with an administrator to say Look these are the things that I finally deciphered from this report."—that is not the thing that is leading to a thousand days before a report is issued. So to argue that to narrow the ability of a coroner to write a recommendation is necessarily going to save time or efficiency is I think a stretch. I think it instead impedes on a coroner's ability to speak to the points that they consider valuable.The specific recommendation that the Chief Coroner spoke to which they were concerned was a narrowing of their ability is in this new section 57A(3)(a) which states that a recommendation must "be clearly linked to the factors that contributed to the death to which the inquiry relates;". We have used a few examples previously but I was just reading about one of many forestry deaths that have tragically occurred in recent years. One determined cause of one of those deaths was that there were high winds in the area when a tree came down on a forestry worker. In that circumstance a coroner may only feel able to make recommendations that relate to the fact that this was an accident obviously caused by high winds that caused that tree to come down. But to what extent are they able to speak to the wider context of fatigue long hours the effects of the way that contracting works within the industry and other factors that may have led to the potential distraction of that worker—the pressure they may have felt to continue to work in those environments? This clause potentially limits a coroner's ability to make those wider recommendations. We thought that was problematic.The second area we have concerns with—and I would have to say that this is a real sticking point for us—is not what was included but what was not included in the bill: the lost opportunity as it were. We have spoken about this at great length. Most people in New Zealand might be surprised to learn that when a coroner makes a recommendation there is no obligation on anyone who might be the subject of that recommendation to reply to respond or to give a written view on that recommendation. Their view may be that it is a ridiculous recommendation and should not be implemented but actually there is nothing to say that they need to say anything at all. That seems to be a crazy situation in that we are funding at great expense to the taxpayer a coronial system that can write a recommendation and a report that can go absolutely nowhere—nowhere except perhaps to the family. It seems ridiculous and I am not the only one to have made that declaration.The Law Foundation recently funded a student from Victoria University to conduct a piece of work—as you can see a sizable piece of work—on the very question of whether or not coroners' recommendations should be responded to on a mandatory basis. What they found and this is of interest is that there were 607 coronial inquiries over a 5-year period. That resulted in 1644 recommendations. There were 309 recipients of those recommendations over 5 years—309 recipients. Government organisations received the highest proportion of recommendations. That is interesting. Those whom we protected in this House by refusing to accept a Supplementary Order Paper that made responding—not implementing; responding—to recommendations mandatory are Government departments. Surely given that this legislature is the one requesting and guiding coroners in the work they do—we are telling them how we want them to operate how we want them to be more efficient how we want their recommendations to be more punchy. But on the flip side we are saying that if you issue recommendations we are not going to make our Government departments do anything with them which seems nonsensical.The report then goes on to describe that the most frequent set of recommendations included transport accidents drowning intentional self-harm and complications of medical or surgical care. This House has an interest in transport accidents. Government departments have a direct role in the way that we regulate in the prevention of transport accidents so it is relevant to us and we should want to know. Drowning—if it is a regulation that relates to the Fencing of Swimming Pools Act we should want to know. Intentional self-harm—of course when it comes to mental health provision we should want to know. I note that the Auditor-General has today issued a report on the reporting and gathering of information around self-harm. Surely amongst that we should be saying: "What is happening to our reporting of recommendations?". Complications of medical or surgical care—again very relevant.The report rightly summarises that the Government review—that is this bill—presents an opportunity to initiate much-needed reforms: "A review that includes few proposals to enhance preventative functions may mean that coroners' recommendations are a 'lost opportunity' to save New Zealanders' lives." That is exactly how we see it.To briefly summarise our remaining concerns what has been well traversed by my colleague Phil Goff includes the Defence Force provisions that were requested in this bill—the reversing of onus so that deaths in hostile action will no longer be the subject of a coroner's inquest. That will occur only if the Attorney-General orders that it occur. Our view is that that should be flipped—it should default to the coroner to add transparency for those families.Those concerns in and of themselves were enough for us to say that although we absolutely support narrowing the number of cases that coroners are having to deal with in order to make them more efficient and to get more timely responses the mechanisms that have been used in this bill went too far. They went too far in our view and there was a lost opportunity as well.On that basis Labour has reluctantly decided that it cannot support this bill. We will be keeping a close eye on the changes though. We do support the general intent but we must be the ones who try to preserve transparency in our system and the ability for coroners to make the recommendations that they feel are necessary for our safety."