Editorial: Let's listen to the coroner

Coroner Dr Wallace Bain has repeatedly made recommendations to try to stop hunters mistakenly shooting other people. Photo / Alan Gibson

The role of a coroner is to establish when, where, how and why a death happened and - crucially - whether anything could be done differently to prevent similar deaths in the future. If so, they make recommendations to that effect.

As the Coronial Services of New Zealand website puts it: "A coroner speaks for the dead to protect the living."

So it must be frustrating for a coroner when his or her recommendations - arrived at after research, questioning and listening to first-hand accounts - are not acted upon. Only for that coroner to be faced with more deaths, in similar circumstances. Coroner Dr Wallace Bain has repeatedly made recommendations to try to stop hunters mistakenly shooting other people.

In 2013, he pointed out Rotorua's James Dodds, shot dead by his hunting companion in 2012, would likely still be alive if recommendations he made after inquests into the similar deaths of William Gillies in 2007 and Rosemary Ives in 2010 had been followed.

After Mr Dodds' death he recommended reviewing the charges available to authorities in hunting accidents and educating hunters about identifying targets, high-visibility clothing and sensor products to stop them shooting companions. He also recommended amending the Firearms Safety Code.

Dr Bain will now conduct inquiries into the deaths earlier this month of Carlos Ngamoki, 27, at Te Kaha, and 11-year-old Connor Phillips, in the Kaingaroa Forest.

He said their deaths brought "sharply into focus" the first three basic rules of the Arms Code, always treating a firearm as loaded, pointing them in a safe direction and loading a firearm only when ready to fire.

He said after the inquiry he would look to make recommendations. Again.

Dr Bain must be wondering if he will again find himself saying someone's child, parent or partner "would still be alive today" if only someone had listened. Our justice system has put its faith in coroners' expertise to try and stop needless deaths.

Dr Bain has been speaking for the dead, perhaps now someone should start listening.