New Zealand Law Society - Coroner Tracey Fitzgibbon: Living a life neatly woven around deaths

Coroner Tracey Fitzgibbon: Living a life neatly woven around deaths

Coroner Tracey Fitzgibbon: Living a life neatly woven around deaths

Contrary to her naturally amiable presence, death has been a familiar subject to Auckland Coroner Tracey Fitzgibbon who was a former police officer surrounded by tikanga protocols in her upbringing. It’s not uncommon to hear people wrongly associate coroners with medical professionals. In fact, an important part of a coroner’s day-to-day task is to explain to families and interested parties of what they can and can’t do under the Coroners Act. Tracey reflects on her path leading to this often misunderstood jurisdiction, and shares her passion to foster a better understanding of the work of coroners.

A career took off in a little-known jurisdiction

“No one really knows what we do, even some of my lawyer friends thought I was medically trained. It’s a jurisdiction that has a lot of unfamiliarity.

“We're actually legally trained judicial officers who conduct investigations into unexplained and unnatural deaths with the view to prevention and public interest, while balancing the views of the family and other interested parties.

“It's a legal job as you need to have a real understanding of legislation, listen to oral evidence, weigh it, to marshal all evidence and make findings."

Tracey is committed to sharing about the work of coroners more widely to bridge gaps, raise awareness and eliminate misconceptions.

“Understandably, people who engage in the coronial service are often hoping to see someone being held accountable for the loss of their loved ones, which is outside of the coronial jurisdiction.

“A lot of my day-to-day work is explaining to families or interested parties of what I can and can't do under the Coroners Act and managing expectations.

“We're a bench that does need to keep educating people on what we do, rather than them finding out when they’ve lost a loved one and come into this jurisdiction, which is the worst time to be learning about something.

“I know it would be inappropriate but I feel we need to do a reality programme about what we do on a daily basis.”

Introduction to dealing with death

Without a shadow of a doubt, Tracey always wanted to be a police officer. As planned, she joined the Police at the age of 18 where she was introduced to attending sudden deaths and interacting with families with the official procedures required.

Being Māori, Tracey was brought up to view death through a tikanga lens. 

“Growing up, it was very much a part of living to understand what happened when someone died and the protocols around that. For Māori, it's a whole process of grieving.

“Attending a tangi is about spending time with a loved one when they've died, being with other family and grieving as a group.”

A private investigator knocking on the door

During her eight years in the police force, Tracey came to the conclusion that shift work was unsustainable while raising a young family, particularly with a husband who was also a police officer at the time in Hawkes Bay. She decided to be a full-time mum, and despite having no concrete plan about her future career, she was offered a job a few years later by a private investigator who was an ex-police officer.

She was asked to help with local investigations that ranged from insurance, ACC to theft and fraud. One of the cases was to privately investigate a sudden death on behalf of a family. This exposed her to the matters around death and working with people affected by them after her stint at the Police.

Solidify my skills with a law degree

Born and bred in Auckland, Tracey along with her family moved back to her hometown in 2006 but soon faced the difficulty of re-entering the workforce without a degree.

“I realised that employers were wanting people with degrees and background – I had experiences but didn't have a piece of paper to solidify my skills.

“A law degree was an obvious choice for me. Coming from a police background where we would be managing disorder at the front line, I was interested in seeing the other end of the process when laws are applied in court.”

Unlike other peers in the class who were already in the academic system, the academic writing was foreign for Tracey as she had not been to university and had to learn from scratch. To balance the family finance, she worked the entire time and eventually completed her law degree in five years.

Another step closer to the coronial jurisdiction

To find a job that would enable Tracey to juggle study and family, it must be after hours and on the weekends so she could study during the day and work at night. A role at the duty coroner's office was a perfect fit.

It saw her supporting the duty coroner on call by taking phone calls about deaths, progressing paperwork, liaising with stakeholders and supporting the coroner with their directions. Thanks to her experience at the Police, she has had the communication skill to take distressing families through the early stage of the process.

Once again, she was brought back to an area that’s primarily about death.

A holding pattern that carves the path

Coroner Tracey Fitzgibbon and Chief Coroner Judge Deborah Marshall

Although Tracey had had a range of work experience by the time she finished the law degree, it did not make it easier for her to decide on her next step as a graduate until an unexpected offer landed.

“I was lucky enough to be offered a role as a case manager for the then newly appointed Coroner Deborah Marshall. She was also a very good mentor to me, and would give me guidance on what my next stage could be in my legal career.

“It was sort of a holding pattern before I really decided what kind of law I wanted to do.”

Tracey then transitioned from that role to work at the Office of the then Chief Coroner, Judge Neil MacLean, as Legal and Research Counsel. Her time in these two roles have been critical in paving the way for the future without her realising it.

“I never really appreciated how these experiences would help me get to where I am today, because I never thought I’d be a coroner. I felt it was too far out of my reach, and I could never do it.”

Stepping out of my comfort zone to fine-tune my legal skills

To broaden her experience in another jurisdiction and understand court operation in depth, Tracey moved on to seek a position in the Public Defence Service to learn from the simplest cases right up to jury trials.

“I can't say how much my career with the Public Defence Service has helped me develop my advocacy and confidence in court. I became used to doing oral submissions and being on my feet on a daily basis. After two years, I thought it was time that I went out on my own.”

“Operating as a barrister sole was seven days a week but I felt the need was in the criminal defence bar for people coming to court by nature of a vulnerable background, and needed the support of a good lawyer to put them in the right direction.”

“Being an ex-police officer was an advantage. I could talk to police officers and police prosecutors openly about resolution as opposed to going to trials, and understand things from their perspective.”

Taking a leap to embrace every opportunity

As Tracey was thinking of sticking with her role as barrister sole for a few more years, she was asked to cover for six months in Hawkes Bay after the unexpected death of a coroner. It was yet another unintentional event that guided her back to the coronial path.

“I really had to think if I should put my life on hold for six months, or keep doing what I’m doing. Common sense prevailed as these opportunities don't come up every day.”

Tracey was appointed as the relief coroner but here came the next question for her – “Do I apply for the permanent coroner position for Hawkes Bay?”

Hawkes Bay was Tracey’s home earlier on in her career as a police officer. Walking into the relief coroner role was an easy segue but it did not give her total confidence that her application would succeed.

“I applied thinking that there will be someone way more experienced than me for this job, so it was much to my delight and surprise that I was successful in my interview.

“I’m pleased that my relatively short legal career wasn’t a negative and all of those past experiences did count, as I would’ve been competing with people that have been practising law for a long time.”

Tracey was eventually transferred back to Auckland when a vacancy was available.

Judge Brandt Shortland, Coroner Tracey Fitzgibbon and Chief Coroner Judge Deborah Marshall

Making recommendations to prevent similar deaths

While there are pure accidents, some of them can be preventable.

“Our cases could vary from a heathy person without any comorbidities, who unexpectedly died at home to an unnatural death connected to a motor vehicle crash.

“Our priority is investigating a death to determine the cause and circumstance of it first and foremost, but also looking into measures that could’ve prevented similar deaths in the future.”

“The easiest example is a motor vehicle crash that involved an environmental factor like configuration of the road, or the driver was alcohol impaired and lost control. 

“We tend to support other organisations that are doing the safety messaging and reinforce their recommendations for prevention because it's really about the public interest in reducing deaths.”

Behind the scenes and the pressures

Tracey says that empathy and patience are two essential qualities that a coroner must have to succeed and sustain in this profession.

“As a coroner, I'm in complete control of the inquiry. Once I have the preliminary documentation I then seek more evidence by requesting reports and information from a range of people like Te Whatu Ora (Heath New Zealand), to piece together what has happened.

“It can be a lengthy and evolving process as you will need to constantly review evidence, request for more, review and request again to make balanced findings.

Tracey is supportive of the Coroners Amendment Bill and positive about the impact it will have on families that are in the system waiting for outcomes.

“We are always challenged by the number of files we hold to resolve our large file load, so there is an immense pressure to get things done as quickly as possible. However, we treat each file on its own merits and make sure families and interested parties feel that sufficient time and energy has been invested in their file. It’s a matter of constantly balancing all these pressures.

“We’re all looking forward to the passing of the Coroners Amendment Bill, which will alleviate some of the barriers within the current Act, and look at ways to speed up the process for files that warrant it. It will also mean some extra positions coming into the jurisdiction to help with the workload.

A therapeutic occupation and its unseen social duty

The coronial system plays a part in those who are probably the most vulnerable in life, to Tracey it’s about supporting the families through the process to help bring closure.

“Coroners are actually therapeutic – we're trying to get people back to a place where they can move forward, and until we finish the investigation families are in the zone of unresolved grief.

“In most cases, it’s a lawyerless process at the very early stage unless an inquest hearing is needed, so you will be interacting with affected families direct who are still grieving for the loss of their loved ones.

“For those who may need legal advice to help them put their concerns in a more appropriate way, we’d suggest that they seek legal support.

“However, there will be people who can’t afford a lawyer but do not qualify for legal aid, which is one of the reasons we would try and look at access to legal support for interested parties, and help lay people as much as we can.

“We will make sure that they are supported by nature of transparency, ensuring they understand the process, and involving them in everything where we can, so they don't feel left out. Certainty is helpful for people to get through the process.”

Let yourself feel the emotions

Tracey was exposed to death as a young child due to her upbringing. Her experience in the Police has helped her build resilience but as a human it’s impossible to not be affected by our emotions. It’s especially difficult for Tracey when the investigation involves babies and children, or everyday people who died of a cause unbeknownst to them and therefore weren’t able come home to their loved ones.

“The way I deal with any emotional distress is that I let myself feel it.

“Most of us on the bench agree that if you get to the point where it doesn't affect you and you don’t feel any emotions, it’s a much bigger problem.

“Talking and going for a walk are really helpful for me. I’d also take a step back and remind myself that people are relying on me to deal with this inquiry in the best way I can to make a fair determination and finding. What I can do for them is to make sure they feel that they've been heard.

“Everyone cries in the Coroner’s Court. When I do inquest hearings, I’d like to give family the opportunity to tell me about their loved one, otherwise where else can we talk about this openly and grieve openly?”

Tracey recommends engaging in wellness resources and learning to share our emotions through the right channel. The secret is to interact with it to benefit from the support available to us. It’s crucial to be mindful of any expectations we have towards ourselves that may seem unrealistic.

Advice to new professionals and fresh graduates

Tracey’s advice was simple – grab hold of every opportunity and make the most of it.

“Whatever you’re going to do as a lawyer or in your legal career, make sure it adds value to you.

“Each job you have in your life is going to account for something further down the track. You’re going to learn from each thing you do so never turn away an opportunity.”

Tracey’s own career path is a true testimonial of her advice to the new starters in the profession.

“Coronial law isn’t an area that people are lining up to come to, as we’re predominantly about deaths and emotional families.

“It is a therapeutic legal career that focusses on fact finding instead of fault finding. Its emphasis is on working together to look at the future focus of death prevention. It's less aggressive than the adversarial environment.”

We are here to chat and answer questions

Tracey encourages lawyers or anyone interested in coronial law to not hesitate to get in touch or participate in the inquest hearings.

“We as a bench are here to provide information, support and encouragement. If you're interested in working in coronial inquests, don’t hold back on asking.

Tracey will be speaking at The Sir Peter Williams Penal Reform Summer Conference about her journey in the coronial law and answer any questions from the floor on Saturday 3 December 2022.

The Ministry of Justice has recently created resources that contain a new video with a factsheet and booklet to assist whānau in understanding the coronial process.

The Law Society has also added "Coronial Law" as a practice area in our Registry, so you can now search for lawyers specialising in it using our Get legal help tool. If you’re a practising lawyer in this field, make sure you select the option in the Registry.  


Quick facts about coroners

  • Coroners don’t do post-mortems. Post-mortems are done by pathologists who will then submit a report to coroners when requested.
  • Coroners are not medical practitioners. They are judicial officers.
  • Coroners only investigate unexplained and unnatural deaths.
  • A coronial inquiry does not decide on civil, criminal, or disciplinary liability.
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