Terror in Chch

Coroners balance culture and process after attack

No two disasters are the same for those who respond. When a man walked into two Christchurch mosques on March 15, 2019 and opened fire, New Zealand’s coroners had to balance the intensive and crucial disaster victim identification process with Muslim cultural considerations.

“On day five, they were pushing at the gates, and knocking at the doors. They were going to take their bodies; they were going to drag them off – their culture demands them."

Deputy Chief Coroner Brandt Shortland said there was a lot of pressure on coroners in the wake of the of the Christchurch mosque attacks in March.

It’s no secret frustrations were high in the days immediately after the attack.

Muslim tradition dictates the body of the deceased be buried by sundown on the day of death.

After a couple of days of no bodies being returned to families, and very little information as to why, tempers began to rise.

On the Sunday, Prime Minister Jacinda Ardern told the nation some bodies would be released to families that evening, and the rest would be released by the following Wednesday.

In the background, those running the coronial process had their heads in their hands. There was no way they could deliver on the Prime Minister’s timeframe while also ensuring the process had integrity and was legally airtight, knowing a trial would be inevitable.

Shortland said it took about two days to get the systems running well, and the identification courts set up. Initially, with 49 bodies and some people of a similar age, name and ethnicity, the identification process was complex.

“I think the lesson here was: everybody’s got an interest in this, and they want it done as soon as possible, but you’ve got one shot of putting the evidence together to do the proper legal process. And if you shortcut that, that’s it, the guy walks away...

“That was difficult to convey to a lot of very staunch Muslim people who were grieving for their loved ones. Yet, you’ve got one chance to do this right.”

Once the identification hearings were underway the process ran smoothly, and efficiently.

Extra disaster victim identification specialists were brought in from Australia. And forensic pathologists were able to use CT scanners to carry out post-mortems in a more timely way. Surgical post-mortems could take hours.

“There could be nothing worse than giving the wrong body to the wrong family, and we find from overseas examples when you try to speed up the process, or miss steps, that is exactly what happens."

Canterbury Muslim community leader Hanif Quazi said the turning point for families and the Muslim community was when Chief Coroner Judge Deborah Marshall addressed the families at Hagley Park, and subsequently spoke publicly about the process.

“It made a huge difference. The understanding was clarified, and they were able to take a sigh of relief,” he said.

Before that, there was “confusion and commotion” due to a range of factors, including the complexity and severity of the attacks, and the dynamics between the different Muslim groups.

Backed by police deputy commissioner Wally Haumaha, Marshall made one of her rare public appearances following the attack.

She said Coronial Services was aware of the cultural issues but had to follow international best practice guidelines when it came to disaster victim identification.

“There could be nothing worse than giving the wrong body to the wrong family, and we find from overseas examples when you try to speed up the process, or miss steps, that is exactly what happens.

“And it’s not going to happen here,” she said.

At the annual Asia Pacific Coroners Society conference last week, Marshall spoke about the identification process, saying one mistake would impact two families. It was crucial they got it right.

Chief Coroner Judge Deborah Marshall spoke to the public about why the return of the bodies was taking so long. Photo: Sam Sachdeva

Days after the attacks, Stuff revealed additional police, including global sharpshooters, were in Christchurch for training as the attack unfolded.

In a strange twist of fate, New Zealand’s coroners were also in the city for their annual training, which included learning about Marshall’s experience at a recent Interpol diaster victim identification conference in Singapore.

The training was due to wrap up at 2pm on Friday, March 15. But it finished early, and by the time news of the attack broke, most people were on flights home.

Shortland’s flight back to Northland wasn’t until 5pm, so he went for a walk in the city centre. He said he thought the high police presence and roadblocks were related to the student climate strike from earlier in the afternoon, so he jumped in a cab and headed to the airport.

His taxi driver was a retired Kurdish man, who had moved to New Zealand from Iraq.

He’d come to New Zealand because it was supposed to be safe, Shortland said, commenting on the irony.

The driver said he’d heard something was happening at his mosque but didn’t have any more information. He thought it was a fire, and he was worried about his son who prayed there.

The man later found out his son had survived but one of his best friends had not.

“One of the things that I think everyone tries to do in a disaster situation, is do it with compassion. I know some of the coroners were crying their eyes out afterwards. The pressure was huge.”

Soon after Shortland landed in Auckland, he received a call from a coroner at the National Initial Investigation Office (NIIO) headquarters to say there was an alleged mass shooting. At that point six were confirmed dead.

The chief coroner triggered the mass fatality plan, and Coronial Services mobilised to get coroners and case managers to Christchurch on the Saturday.

Staff met with police and pathologists, setting up makeshift identification courtrooms at the police station.

In a perfect world, police gathered evidence in order to identify the person, they get the right name to the coroner, then the coroner directed the post-mortem, Shortland said.

“The police only really have one chance to prove beyond reasonable doubt that someone has killed somebody."

Dr Hanif Quazi says families were confused and angry. The turning point was when the chief coroner gave them the information they were looking for. Photo: Supplied

The experience of the Pike River disaster and Christchurch earthquakes were invaluable to Coronial Services, Shortland said.

Those coroners who had worked together in the wake of the earthquakes swiftly flew into action.

There was never any formal training for a disaster and no two disasters were the same, but between some basic principles and the Number 8 wire mentality, those on the frontlines got the job done.

While the group of coroners and support staff were working on the response in Christchurch, Shortland was leading the coroners’ ‘business as usual’ programme.

Aside from the attacks, it was one of the busiest days of the year for deaths being referred to the coroner.

Following the earthquakes, Coronial Services turned its full attention to the diaster, leaving others around the country feeling neglected. They weren’t going to make that same mistake again.

In the end, those who took jurisdiction of the bodies following March 15 carried out their duties with sensitivity and compassion, Shortland said.

“It’s a reminder it’s not what we do, it’s how we do it.”

There were lessons to be learnt when it came to communicating with families and the public, and coroners could always improve their cultural competency and sensitivity, he said.

“As coroners you’ve got to build trust with other communities. The Muslim community is one of those we haven’t had a lot to do with... They usually stay under the radar and don’t cause any controversy.”

“It does affect people, it does affect coroners, it does affect professionals... But you’re dealing with the worst disasters humans can throw at each other, and experience, and sometimes it’s not until you’re in the firing line 'til you find out where you’re at.”

The attacks also had an impact on staff.

Staffing numbers were low at the time of the attacks, and people were working long hours.

“One of the things that I think everyone tries to do in a disaster situation, is do it with compassion. I know some of the coroners were crying their eyes out afterwards. The pressure was huge.”

Shortland had never previously taken up the offer of professional mental health supervision, but the attacks affected him, and for the first time, he asked someone to check his mental health.

“It does affect people, it does affect coroners, it does affect professionals, and you’ve got to find a way to get back on the horse when you fall off, and get on with your job, and try and be objective.

“But you’re dealing with the worst disasters humans can throw at each other, and experience, and sometimes it’s not until you’re in the firing line 'til you find out where you’re at.”

Quazi said he had spoken to the victims’ families a lot since March 15, “and their message was that they were very satisfied with the way the coroners did their job”.

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