This is an HTML version of an attachment to the Official Information request 'Coroner and Avoidable Ambulance Deaths'.

Justice Centre | 19 Aitken Street 
DX SX10088 | Wellington 
T 04 918 8800 | F 04 918 8820 
[email address] | www.justice.govt.nz 
 
 
5 December 2024 
 
Lauren Doocy 
By email: [FYI request #29027 email] 
Our reference: OIA 117279 
 
Tēnā koe Lauren,  
 
Request for Coroners Court information regarding ambulance service related deaths 
 
Thank you for your request of 2 November 2024 to the Office of Hon Paul Goldsmith, 
Minister of Justice, seeking information related to ambulance service related deaths. Your 
request was transferred to the Ministry of Justice (the Ministry) on 6 November under section 
14 of the Official Information Act 1982 (the OIA), as it more closely aligns with the functions 
of the Ministry. I am responding to your request under both the Coroners Act 2006 (the 
Coroners Act) and the OIA. Your request is made up of six parts. 
 
 
 
 
1.  Advice the minister has received from the chief coroner about these cases. 
 
The Ministry is responding to part 1 of your request under the OIA.  
 
In order to respond to part 1 of your request, the Ministry has consulted with the Office of 
Hon Paul Goldsmith who have confirmed that the Office does not have any record of 
receiving any information from the Chief Coroner on this topic. Therefore, I am refusing this 
part of your request under section 18(g) of the OIA as the information requested is not held 
by the Minister, nor are there grounds for believing that the information is held by or 
connected more closely with the functions of another department, Minister of the Crown, or 
organisation. 
 
2.  Figures related to the number of cases that the coroner is currently investigating 
about ambulance service-related deaths. 
 
The Ministry is responding to part 2 of your request under the Coroners Act. 
 
In response to this part of your request, please see Table 1 enclosed. Table 1 provides the 
total number of active cases referred to the coroner where the death occurred in an 
ambulance or ambulance depot from 1 November 2019 to 31 October 2024. 
 
3.  Figures related to the number of cases that the coroner has investigated in the 
past five years about ambulance service-related deaths. 
 
The Ministry is responding to part 3 of your request under the Coroners Act. 
 
In response to this part of your request, please see Table 2 enclosed. Table 2 provides the 
total number of closed cases where the death occurred in an ambulance or ambulance 
depot, notified to the coroner between 1 November 2019 and 31 October 2024. 

 
 
 
4.  Figures related to the number of cases that the coroner has decided to pass to 
other agencies, which raise concerns about ambulance service-related deaths
 
The Ministry is responding to part 4 of your request under the Coroners Act. 
 
In response to this part of your request, please see Table 3 enclosed. Table 3 provides the 
number of closed external investigation cases where the death occurred in an ambulance or 
ambulance depot notified to the coroner between 1 November 2019 and 31 October 2024. 
 
A closed external investigation case is one in which the coroner is satisfied that the death is 
being investigated under an enactment other than the Coroners Act, and therefore the 
coroner does not conduct an inquiry into the death. Please refer to sections 68 and 69 of the 
Coroners Act for more information. 
 
5.  To what extent does the coroner currently not investigate ambulance service-
related deaths due to concerns about resourcing? 
 
The Ministry is responding to part 5 of your request under the OIA. 
 
Part of the coroner’s role includes deciding whether to open and conduct an inquiry into a 
death. The coroner makes their decision based on the evidence available to them for each 
individual death. As coroners are independent judicial officers, the Ministry is unable to 
comment on their decision-making or how they conduct their investigation. A coroner’s 
deliberations are court information which is excluded from the OIA as per section 2(6)(a). 
Therefore, I am refusing this part of your request under section 18(g) of the OIA as the 
Ministry does not hold the information you have requested, nor are there grounds for 
believing that the information is held by or connected more closely with the functions of 
another department, Minister of the Crown, or organisation.  
 
6.  Provide any briefs, emails or meeting minutes from the past year that relate to 
concerns about inadequate funding of the coroner's office, preventing timely 
investigation of deaths notified to the coroner. 

 
The Ministry is responding to part 6 of your request under the OIA. 
 
The Ministry has interpreted ‘coroner’s office’ to mean the Coroners Court. The Ministry does 
not hold any information for the period from 2 November 2023 to 2 November 2024 relating 
to funding constraints that impact timeliness in the Coroners Court. Therefore, I am refusing 
this part of your request under section 18(g) of the OIA as the information requested is not 
held by Minister of the Crown, nor are there grounds for believing that the information is held 
by or connected more closely with the functions of another department, Minister of the 
Crown, or organisation. 
 
If you require any clarification of the information contained in this response, please contact 
Joe Locke, Media & Social Media Manager, on 021 636 416, or email [email address]  
If you are not satisfied with the decision on information released to you under the Coroners 
Act 2006 you can make a complaint to the Chief Coroner. The Chief Coroner may be 
contacted by email at [email address] or by writing to the Office of 
the Chief Coroner at DX SX 11166, Wellington. 


 
 
If you are not satisfied with the decision on information released to you under the OIA, you 
have the right to complain to the Ombudsman under section 28(3) of the OIA. You can 
contact the Office of the Ombudsman by calling 0800 802 60; or emailing 
[email address] 
 
I trust this information assists. 
 
Nāku noa, nā 
 
 
Andrea King 
Group Manager, Senior, Employment, Environment and Coroners Courts 
 
Encl:   
Table 1: Total number of active cases referred to the coroner where death 
occurred in an ambulance or ambulance depot from 1 November 2019 to 31 
October 2024 
Table 2: 
Total number of closed cases where death occurred in an 
ambulance or ambulance depot notified to the coroner between 01 November 
2019 and 31 October 2024 
Table 3: 
Number of closed external investigation cases where death occurred 
in an ambulance or ambulance depot notified to the coroner between 01 
November 2019 and 31 October 2024 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Table 1: Total number of active cases referred to the coroner where death occurred in 
an ambulance or ambulance depot from 01 November 2019 to 31 October 2024 

 
 
 
•  This data may differ from previously released or published data. This data was 
extracted from the Court’s Case Management System as of 26 November 2024. 
•  Cases are included based on the date the case was notified to the coroner (this can 
differ from the date of death). 
•  This data includes active cases. Active cases are currently under investigation by the 
coroner; therefore, this information is provisional. 
•  This data counts instances where "Ambulance" or "Ambulance depot" is recorded as 
the location in which the death occurred. 
•  Due to the way information has been recorded by, or presented to the coroner, the 
statistics provided should not be taken as representing every such instance. 
•  To find the information you have requested, we searched key words in the Court’s 
Case Management System, meaning the search was dependent on the way in which 
the information was received and recorded. It is therefore possible that we have not 
identified all cases related to deaths that occurred in an ambulance. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Table 2: Total number of closed cases where death occurred in an ambulance or 
ambulance depot notified to the coroner between 01 November 2019 and 31 October 
2024 

 
 
 
•  This data may differ from previously released or published data. This data was 
extracted from the Court’s Case Management System as of 24 November 2024. 
•  Cases are included based on the date the case was notified to the coroner (this can 
differ from the date of death). 
•  This data includes closed cases. Closed cases have been heard by the coroner and 
findings have been issued. 
•  This data counts instances where "Ambulance" or "Ambulance depot" is recorded as 
the location in which the death occurred. 
•  Due to the way information has been recorded by, or presented to the coroner, the 
statistics provided should not be taken as representing every such instance. 
•  To find the information you have requested, we searched key words in the Court’s 
Case Management System, meaning the search was dependent on the way in which 
the information was received and recorded. It is therefore possible that we have not 
identified all cases related to deaths that occurred in an ambulance. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Table 3: Number of closed external investigation cases where death occurred in an 
ambulance or ambulance depot notified to the coroner between 01 November 2019 
and 31 October 2024 

 
 
 
•  This data may differ from previously released or published data. This data was 
extracted from the Court’s Case Management System as of 26 November 2024. 
•  Cases are included based on the date the case was notified to the coroner (this can 
differ from the date of death). 
•  This data includes closed cases. Closed cases have been heard by the coroner and 
findings have been issued. 
•  This data counts instances where "Ambulance" or "Ambulance depot" is recorded as 
the location in which the death occurred. 
•  We have interpreted your request to mean cases where the coroner did not conduct 
an inquiry, as per section 68 or 69 of the Coroners Act 2006. 
•  Due to the way information has been recorded by, or presented to the coroner, the 
statistics provided should not be taken as representing every such instance. 
•  To find the information you have requested, we searched key words in the Court’s 
Case Management System, meaning the search was dependent on the way in which 
the information was received and recorded. It is therefore possible that we have not 
identified all cases related to deaths that occurred in an ambulance. 
•  A Cor 9 refers to a decision by the coroner not to conduct an inquiry under section 68 
of the Coroners Act. 
•  A Cor 10 refers to a decision by the coroner not to conduct an inquiry section 69 of 
the Coroners Act.