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1. HM v B Ltd [2021] NZDT 1553 (3 August 2021) [pdf, 238 KB]

   ...the bolts sheared off; that the bolts were worn; and that the holes were elongated and slightly off-centre to accommodate the new coupling when it was added, but he says these issues did not cause the Event, rather, he says that the bolts sheared off suddenly when the Trailer jack-knifed into the Trailer. SX concludes that although there were pre- existing issues with the Trailer, these did not cause or contribute to the Event, rather, the bolts sheared off when the Trailer jack-knifed int...

2. Rec-Recap-2023-Q4-FINAL.pdf [pdf, 873 KB]

   ...Office of the Chief Coroner | 2023 (4) i Coroners’ recommendations and comments Coroners perform essential functions within our society. They inquire into a range of unexpected deaths to establish the identity of the person who has died and the cause and circumstances of their death. While inquiring into a death, a Coroner may make recommendations or comments for the purpose of reducing the chances of further deaths occurring in circumstances similar to those in which t...

3. Rec-Recap-2024-Q1-FINAL.pdf [pdf, 873 KB]

   ...Office of the Chief Coroner | 2024 (1) i Coroners’ recommendations and comments Coroners perform essential functions within our society. They inquire into a range of unexpected deaths to establish the identity of the person who has died and the cause and circumstances of their death. While inquiring into a death, a Coroner may make recommendations or comments for the purpose of reducing the chances of further deaths occurring in circumstances similar to those in which t...

4. Recommendations Recap Issue 17 [pdf, 562 KB]

   ...Office of the Chief Coroner | 2018 (3) i Coroners’ recommendations and comments Coroners perform essential functions within our society. They inquire into a range of unexpected deaths to establish the identity of the person who has died and the cause and circumstances of their death. While inquiring into a death, a Coroner may make recommendations or comments for the purpose of reducing the chances of further deaths occurring in circumstances similar to those in which...

5. MOJ0047.03_factsheet_JUL23-Samoan_WEB.pdf [pdf, 222 KB]

   ...sē e pele ia te oe. O le case manager na tofia e galulue faatasi ma le tagata e suesueina mafuaaga lilo o maliu o ia lea e te fesootai i ai, ma e faafesootai atu oe e auala atu i se imeli po o le pusa meli. E tuuina atu ia te oe se tusi faamatala When Someone Dies Suddenly, e maua ai isi faamatalaga i tulaga e tatau ona faamoemoe i ai mo masina o sosoo ai. O le a lafo atu foi e le case manager ia te oe, po o se isi tagata o lou aiga, nisi faamatalaga e tusa ma le faagasologa o le suesu...

6. Recommendations recap - issue 7 [pdf, 1.4 MB]

   ...(recreational fishing and boating) 30 Acronym glossary 31 Index Contents 1 Adverse effects or reactions to medical or surgical care Case number CSU‑2011‑DUN‑000181 2013 NZ CorC 106 CIRCUMSTANCES The deceased, an 81‑year‑old man, died at Southland Hospital of an intracranial haemorrhage. The deceased had a history of heart problems and had been fitted with a pacemaker five months before his death. He was admitted to hospital following three weeks of breathless...

7. Recommendations recap - issue 5 [pdf, 1 MB]

   ...boating) 61 Work-related (agriculture) 62 Work-related (other) 68 Acronym glossary 69 Index Contents 1 Adverse effects or reactions to medical/surgical care Case number CSU-2011-DUN-000270 2012 NZ CorC 165 CIRCUMSTANCES The deceased died at Dunedin Hospital of an injury to her brain, which occurred when a naso-gastric tube was incorrectly inserted following a procedure to relieve a build-up of fluid around the brain and spine. Two days after the tube had been insert...

8. Recommendations recap - issue 4 [pdf, 832 KB]

   ...he or she is satisfied that another investigation into the death is being conducted that is likely to establish the matters that a coroner is required to establish. These matters include the identity of the deceased, when and where the person died, and the causes and circumstances of the death. If the coroner is satisfied that the other investigation has adequately established these matters, he or she may decide not to open or resume the inquiry (Coroners Act 2006, s70). The eff...

9. Recommendations Recap 2024 Q2 [pdf, 884 KB]

   ...position of the glider exerted forces on the tail of the tow plane, exacerbating the turn and potentially preventing Mr Lowen from returning to the wings level position some expert witnesses advocated as required once the glider was out of position. When the rope became taut again after being slack, the upset occurred. It was found that Mrs Loader was in the best position to release and had the greatest responsibility to do so. Her failure to do so was in breach of the guidelines curren...

10. Rec-Recap-Q3-2022.pdf [pdf, 691 KB]

    ...Office of the Chief Coroner | 2022 (3) i Coroners’ recommendations and comments Coroners perform essential functions within our society. They inquire into a range of unexpected deaths to establish the identity of the person who has died and the cause and circumstances of their death. While inquiring into a death, a Coroner may make recommendations or comments for the purpose of reducing the chances of further deaths occurring in circumstances similar to those in which t...