There are concerns changes to the Coroners Act could lead to the cause of deaths in custody or state care being covered up.
Photo: RNZ
A bill before Parliament proposes changing the Act to remove the requirement for an inquest to be held every time a death happens in custody or state care.
Instead, it would be left to the discretion of coroners to decide whether an inquest is necessary.
Dave MacPherson's 21-year-old son, Nicky Stevens, drowned in the Waikato River in February while under a compulsory care order in a mental health unit at Waikato Hospital.
Mr MacPherson said that being told within a day of his son's body being found that there would be an inquest had at least given the family some hope that the truth about what happened would come out.
He said not having that certainty would make it much harder on bereaved families.
Mr Macpherson said the proposed changes would put families in a terrible position.
"Not knowing whether they're going to even be able to go along, express their views and have questions asked of the other people involved. That's going to be a real problem, that's going to make it that much harder, sort of, in the situation that we've been in."
Inquests expose faults
Queen's Counsel Nigel Hampton said time after time inquests had exposed improper care in custody or in mental health units.
"If there's allowed to be a hole, a discretionary hole, in the scrutiny of such deaths," said Mr Hampton, "then I'm afraid that it will be used, or can be abused, from time to time, as an escape hole for things that haven't gone right and things that might well be covered up."
Under the proposed changes, the coroner would hold an inquiry into any deaths in custody or state care, and would make a decision on whether a full inquest is needed.
But Mr Hampton said often inquests are needed to get the full story.
"Often the full extent of the care, or lack of care, is not revealed until you get to a proper coroner's inquiry where people have to give evidence on oath, where they are subject to examination and cross examination.
"And the coroner, in doing that gatekeeping role, will only see what the authorities want him or her to see."
Lessons 'will go unnoticed'
Susan Barriball said without an inquest no lessons would have been learned from her brother Richard's death by suicide while he was in prison in 2010.
She said the police just saw her brother's death as suicide. "Cut and dried. Yes, it was suicide but there was a lot of things that led to that suicide," she said.
"Including him not getting his correct medications delivered to him. So it's those kinds of things that are going to go unnoticed, unpicked up and the bad practice will just be able to continue."
Victoria Davis' son Jai Davis died from a drug overdose while on remand in Otago prison in 2011.
She said the inquest found systemic failures led to the death of her son, but that wouldn't have been identified without the inquest.
"It wasn't until my lawyer and I got onto the bandwagon for even the police to actually investigate my son's death," says Ms Davis.
"The coroner's only as good as the information that he gets from the people that may be giving him the information. But to have an inquest, it's much more in-depth."
The Coroners Amendment Bill has had its first reading and is before the Justice and Electoral select committee.