After nearly three years the inquest was finally held into the death of Deb's daughter Cloudy. Deb had two key objectives - to challenge the secrecy around suicide in NZ and to present evidence that would lead the coroner to make recommendations for change in a number of areas.

The first objective was met. The Coroner overturned the presumption in favour of secrecy and allowed unfettered reporting of the inquest by the media. In doing so, he firmly rejected the advice of the Ministry of Health and SPINZ that talking about suicide leads to copycat suicide. The evidence put forward by these agencies to support their position is incredibly weak with the literature review underpinning their media guidelines being 11 years old. The evidence that media reporting can be beneficial is ignored by them but the Coroner was clear his decision to allow reporting was because he believes it is beneficial. We hope other Coroners follow the lead of the head of their bench.

The second objective however was not met. The Coroner made no recommendations for change. The process he employed showed his complete lack of interest in uncovering the truth about what had happened to Cloudy and how deaths such as hers may be prevented in the future.

Anyone who knows Deb knows that wherever she goes she takes photos of Cloud and blutac. If she arrives at your place for dinner or coffee the pictures will go up on your wall within minutes of her arrival. Deb has very strong spiritual beliefs and is part of a group which actively practices these. Having images of Cloud and certain items with her is part of that culture. In Toran's inquest Deb put up pictures of Toran on the wall of the Courtroom and many witnesses stopped to look at them before giving evidence. Some told me it helped to remember that Toran was a real live person not just a case number while they were giving evidence. It certainly helped me to be able to look at him.

So of course the first thing Deb did on arriving at Court was to put her pictures of Cloud on the wall. This was particularly important to her as the Coroner had refused to let her play a short DVD of Cloud to introduce her to the Court. Within minutes, the Coroner's assistant Merelyn Redstone scurried off to inform the Coroner that this had happened and returned to announce triumphantly that the coroner would not enter the courtroom until Cloudy's image had been removed.

There was stunned silence in the Courtroom. The media and Cloud's family and friends were shocked. Demanding that Deb remove Cloud's picture is akin to demanding a Muslim woman remove her headscarf. Deb burst into tears. She said she wanted some time to consider the Court's demand and went out to the waiting room to gather her thoughts. In the manner of a school prinicipal Ms Redstone loudly announced that the inquest would start in 5 minutes 'with or without the family.' In Toran's inquest the Coroner stated at the beginning of the proceedings that as Toran's mother I was the most important person in the courtroom. It was clear that at Cloudy's inquest Deb was not to be accorded the same respect and this was a strong theme of the 2 day proceeding.

The police investigation into Cloud's death had been totally inadequate and this has been acknowledged by the Dectective Inspector asked to take it over 8 months after she died. The statement taken from Deb at the scene took 8 minutes to complete and gathered little more than Deb's name, age and contact details. Other witnesses were not interviewed for between 8 months and almost 3 years after the event. Important evidence was not gathered or was destroyed. The file was sent back to the police by the Coroner after Deb complained. The police were very open about the fact that the conclusions they reached about Cloud's death were based on opinion rather than evidence. A week before the hearing they were still interviewing witnesses despite the fact that their memory of events was very hazy nearly three years down the track.

Deb began to question the police about their processes. The purpose of this questioning was not to criticise the police but to raise issues around the reliability of the evidence before the Court. The Coroner however immediately shut down this line of questioning. In the end it meant that his findings contained a number of factual inaccuracies as a result of his failing to allow Deb to show the Court where there were errors in the information before the Court.

Here's an example. The Court had evidence that Cloudy had been to family planning on 13 November 2007 and been given a prescription for the contraceptive Norimin. Her GP records showed that she had seen him on 15 November and appear to show she got a prescription for a different contraceptive, Estelle 35 from him. Deb spoke to the GP about this and he explained that the records he had provided were missing a date on the second page which would have showed that in fact his prescription to her was in 2006. Further invesigation showed that Estelle 35, while working as a contraceptive is not allowed to be prescribed for that purpose because of its risks but is prescribed for the treatment of acne. The Coroner however in his verdict stated that on 15 November 2007 Cloud had been to her GP and recieved a prescription for the contraceptive Estelle 35. This is just one example of lack of thorough investigation by the Court and ignorning the evidence of Cloud's family resulted in the Coroner being wrong in fact. It is indicative of the lack of committment the Coroner's Court has to truth and accuracy despite the critical task it has of preventing further suicides.

Cloudy's boyfriend Jack was a key witness in the proceedings. To the surprise of everyone he turned up in his police uniform despite not being on duty. It may be for this reason that when the evidence he gave in the court completely contradicted his statement to the police the Coroner said he would accept the evidence given in Court and ignore the earlier statement to police. The police lawyer said to Jack at the beginning of his evidence that they had been over his testimony and he had a document in front of him that he read from and which contained answers to the questions the police asked him. Another witness who had not been interviewed at the scene went to the Coroner's office three weeks after Cloudy's death and gave a statement to the Coroner's assistant as he considered his evidence important and something that should have been gathered by the police. Interestingly he had been contacted by the police days before the hearing and encouraged to change his evidence from that given in this statement, something he refused to do.

Deb had asked for most of those who gave statements to the police and the attending police officers to be called as witnesses so she could question them. The Court refused to do so. What the Court did invest a lot of effort in however was trying to obtain evidence that Cloudy had a psychiatric disorder. Her friends and family, GP, family planning doctor and hospital records showed that this was a complete dead end. There was no evidence that Cloudy suffered depression or any other mental illness with her GP who saw her two months before her death saying he vividly recalled her as a bright, bubbly young woman. Clearly while rejecting the advice of the MOH and SPINZ about media reporting, the Coroner still accepts their incorrect advice that those who commit suicide are mentally ill.

While not actually making a recommendation, the Chief Coroner opined in his decision that it may be useful to employ psychologists or psychiatrists to conduct psychological autopsies in suicide cases. If he had done his homework, the Coroner would know that a psychological autopsy should be performed by a forensic investigator not a psychiatrist. The purpose of a psychological autopsy as originally conceived is to gather and analyse information about the circumstances leading up to a suicide. This inforamtion includes data on social stressors, financial pressures, relationship break ups, work or school difficulties, physcial and mental health issues. In NZ this process has been co-opted by psychiatrists and is limited to conducting a mental health assessment on the person who has died. A psychological autopsy conducted by a psychiatrist will identify for example sleep disturbance and apply a diagnosis of 'sub-threshold depression' while a proper psychological autopsy would consider the context in which the sleep disturbance occurs.

The Coroner correctly pointed out that the inquest process as conducted for Cloud was a 'psychological autopsy of sorts.' Yes sir, and that is what your court should be conducting. The police investigate on your behalf. They have no specific training in conducting a psychological autopsy but this is exactly what they should be doing and this has been our point all along. You don't need to introduce yet another process involving psychiatrists but focus on ensuring the police act as forensic investigators (and have appropriate training to do so) and that your court considers the evidence presented at the end of this process and determines what were the relevant factors which lead to the persons death. Really what you are suggesting is that the Coroner's Court do a more thorough job of collecting and analysing the evidence available in suicide cases. We support that 100% and have spent 3 years advocating for it.

Getting back to Cloud's inquest, the second day was simply returning to Court to hear the Coroner deliver his verdict. Judge MacLean entered the Courtroom and immediately began reading his decision. He did not acknowledge Deb and did not once make eye contact with her during the process. After reading the last word, he stood up and almost ran from the Courtroom. Every morning in Toran's inquest the Coroner would start the proceedings by acknowleding everyone in the Courtroom and saying "good morning Ms Bradshaw" to me. In delivering his verdict he acknowledged the love my son and I had for each other. At the end of the inquest he left the bench and came over to me. He offered his condolences, said he hoped the process had helped me and wished me well for the future.

Deb on the other hand was rendered completely invisible. Despite overwhelming evidence that Deb and Cloudy adored each other their relationship was not acknowledged at all by Judge MacLean. He did not once display any humanity towards a mother who has been devastated by the loss of her child and who appeared before him 10 days before Christmas. He did not wish her well or even recognise her presence in the Courtroom.

Is this really the best our justice system has to offer in terms of suicide prevention?

Maria