Coronial Inquest

Conducted by Coroner Gordon Matenga.

Stella Cheersmith

Two Coronial Inquests were held in Christchurch following the earthquake on 22 February 2011, and both investigated the deaths of those recovered from the CTV building. The first inquest was to identify the nine remaining bodies from the collapse that had not yet been issued death certificates. The second inquest – conducted in two parts – was initially postponed due to strong aftershocks on the first day. Part One of the second inquest was held with the purpose of determining the cause of 106 deaths from the CTV building, while Part Two investigated the deaths of those that were known to have survived the initial collapse but remained trapped in the rubble. The inquest concluded in December 2012, and Coroner Gordon Matenga released his report in March 2014.

First:

Christchurch Press 5 May 2011: Section A, Page 5 | "Inquest 'recognises missing son's fate'." - Reports on the announcement of the Inquest, due to be held from May 16-18 at Riccarton Park Racecourse. The purpose of the inquest is to identify the remaining nine bodies from the CTV collapse and issue death certificates for these victims.
Christchurch Press 17 May 2011: Section A, Page 1 | "Inquest reveals grim details." "Mother hears of final hours." - This page of The Press contains two articles about the Coronial Inquest. The first discusses the nine bodies unable to be identified by DNA, dental records, and pathology tests. Circumstantial evidence allowed Chief Coroner Judge Neil MacLean to confirm the names of these nine bodies, all of whom were victims of the CTV collapse. The second article gives details on the mother of one of these victims, Marlene Sumalpong, who attended the inquest. Her daughter initially survived the earthquake but remained trapped in the rubble, though her cellphone was used by a nearby student (Jessie Redoble) to contact two friends. Neither student was rescued.

Second (Part One):

Started on June 13, postponed to August 29

Christchurch Press 14 June 2011: Section A, Page 6 | "Inquest into CTV deaths disrupted by aftershocks." - Reports on the two large aftershocks that occurred on 13 June 2011, disrupting the Second Coronial Inquest when it had only just begun. The inquest was to determine the cause of 106 deaths in the CTV building.
Christchurch Press 30 August 2011: Section A, Page 2 | "Part of rescue effort to be probed." - Details the start of the Coronial Inquest, and the plans of Waikato Coroner Gordon Matenga to investigate the rescue efforts at the CTV building site. At the time of the article, Police had given evidence relating to the deaths of 21 people in the CTV building.
Christchurch Press 3 September 2011: Section A, Page 16 | "Inquests treat calamity with compassion." "'Long, arduous week' for seasoned officer." - Two articles that cover some of the recent events of the inquest. The first gives a detailed account of the atmosphere at the inquest, as well as a summary of the proceedings and outcomes. The second is an interview with Detective Inspector Paul Kench, who read much of the evidence at the inquest, so causes of death could be determined.

A newspaper infographic depicting the outline of man in work gear and a hard hat, accompanied by the words "CTV INQUEST"

Credit: The Press, Fairfax Media New Zealand. Source: https://quakestudies.canterbury.ac.nz/store/object/223343

Second (Part Two):

The Second Coronial Inquest was adjourned in September 2011, as it was dependent on outcomes from the Royal Commission of Inquiry, which had been delayed. The Coronial Inquest resumed in October 2012.

Christchurch Press 25 October 2012: Section A, Page 11 | "Focus on live victims as inquest resumes." - Provides an update on the inquest, due to resume at the end of October 2012. This article includes some statements from Coroner Gordon Matenga, who addresses the fact that many victims of the CTV collapse were from overseas. The inquest would focus on six victims that survived the initial collapse, but died hours later.
Christchurch Press 31 October 2012: Section A, Page 3 | "Official halted debris clearing." "'We wish we had saved more people'." - Two articles containing information on recent evidence given to the inquest by those who were on the CTV site after the building collapsed. They discuss some of the issues with communication and chain of command, as there were disagreements between the Police, the Fire Service, and Urban Search and Rescue (USAR) as to who was in charge of the site.
Christchurch Press 1 November 2012: Section A, Page 2 | "Officer recalls bid to free trapped woman after calling her on phone." - Details Constable Stuart Martindale’s conversation with Dr Tamara Cvetanova, who managed to contact the rescue team via cell phone while she was trapped in the rubble of the CTV building with a group of women. Though Martindale searched the area where the group was thought to be, the women were not rescued.
Christchurch Press 2 November 2012: Section A, Page 3 | "Rescue gear was 'held up by red tape'." "Contractor 'was not allowed to use machinery'." - Two articles that detail some of the recent evidence given at the inquest by contractors and engineers onsite after the CTV collapse. It discusses some of the frustrations with delays and health and safety issues slowing work that may have saved victims trapped in the rubble.
Christchurch Press 3 November 2012: Section A, Page 5 | "Fireman was 'not in charge'." "NZ rescuers too few for quake." - Two articles discussing the evidence given on the fifth day of the inquest by Fire Officers and USAR members David Berry and Jim Stuart-Black. They discuss the situation at the CTV site, including the chain of command and strain on manpower and resources.
Christchurch Press 9 November 2012: Section A, Page 2 | "Officer sorry he did not take over site." "City's rescue crews refused to take breaks." - Two articles about the ninth day of the inquest, which heard from Fire Service Assistant National Commander Trevor Brown and USAR Task Force Leader Paul Burns. Brown admitted he should have taken over as commander on the CTV site, while Burns discussed the health and safety issues during the rescue effort, such as emergency responders showing reluctance to take breaks.
Christchurch Press 10 November 2012: Section A, Page 2 | "Anger over rescue confusion." - This article details the evidence given at the inquest by National USAR Manager Murray Binning and Flight Lieutenant Kylie Upton. Both discuss the process of transporting personnel and rescue gear from Auckland to Christchurch to assist with the CTV rescue operations. There were complications with the loading of equipment onto the plane, which delayed the flight by at least four hours.
Christchurch Press 7 December 2012: Section A, Page 2 | "Coroner chokes up at closure." "Rescue outstanding, says US expert." - Two articles covering the final days of the Second Coronial Inquest. The first details some of the emotional closing statements, as well as a summarised list of “Five Key Moments” to the right of the page. The second article contains statements from Ernesto Ojeda, US expert in emergency response and Urban Search and Rescue efforts.

Outcome:

Coroner Gordon Matenga published his findings from the inquest in March 2014. The full report can be found here.

Christchurch Press 31 March 2014: Section A, Page 1 | "Rescuers cleared of blame." - This article provides a summary of Coroner Gordon Matenga’s report on the Coronial Inquest. Matenga concluded that more resources and better communication – particularly senior Fire Service staff establishing a command post and more efficient transport of USAR gear – would have increased the chances of rescuing more survivors, but that these shortcomings did not contribute to the deaths of the eight trapped survivors.

A newspaper infographic discussing Coroner Gordon Matenga's report into the rescue efforts at the CTV building. It includes a stylized drawing of the rubble, with a digger and human outlines representing the rescuers. It also includes a picture of Coroner Gordon Matenga and text that reads, "At least five of the trapped were still alive 12 hours after the earthquake at 12.51pm on February 22. The disaster revealed failures of planning, preparation and scene management by the NZ Fire Service."

Credit: The Press, Fairfax Media New Zealand. Source: https://quakestudies.canterbury.ac.nz/store/object/328757

Christchurch Press 31 March 2014: Section A, Page 5 - This page contains some key points from Matenga’s report, listed at the top of the page under “Rescue Lessons”. It includes infographics of the victims’ locations and a timeline of “Signs of Life from the Rubble”. The bottom of the page includes photographs and a short biography of each of the eight victims.
Christchurch Press 21 November 2014: Section A, Page 7 | "Lawyer attacks Government over quake-rescue failings." - This article details statements made by lawyer Nigel Hampton, QC, who represented some of the families of the eight victims trapped in the rubble of the CTV building. Hampton criticised some of the conclusions from Coroner Gordon Matenga’s report and argued that a further investigation of the search and rescue failings needed to be undertaken by the Government.

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General Searches:

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