Source: Radio New Zealand
Selwyn Rabbits is calling for more transparency and action after a coroner delivered a clear message. Nick Monro
After a years-long inquiry into the death of an Auckland construction worker, a coroner has delivered a clear message.
Cardan shaft parking brakes, the braking system used by a piece of heavy machinery that failed and caused Graeme Rabbits’ death, are inherently unsafe, Coroner Erin Woolley found.
She made a series of recommendations to reduce the chances of further deaths, but there is no requirement for the organisations they’re aimed at to follow them or say why they’re not accepted.
Graeme Rabbits father Selwyn, who for eight years launched his own investigation into the braking system, said a formal register of recommendations and responses to them was required.
It’s an idea that’s gained support, although it’s not on the radar of officials.
Plea for transparency
When Graeme Rabbits parked a telehandler – a heavy machine that does the work of a crane and a fork lift – on a slope at an Auckland construction site in January 2018, he had no idea the braking system could fail.
But as he attached a tow rope, it did just that, rolling on to him, causing fatal injuries.
Coroner Woolley’s investigation concluded the braking system’s not safe, and she made a series of recommendations, such as better registration practices and publicity campaigns.
Graeme’s father Selwyn Rabbits said he worried her work might be left to languish.
“The organisations are not obliged to follow the coroner’s findings, but there should at least be some formal process where the organisation has to respond to the findings and justify why they don’t accept them or reject them.
“That should go to a level that gives some transparency and exposure.”
Graeme Rabbits is remembered for his love of the outdoors and going out of his way to help others. Supplied
Many of the recommendations were directed at the NZ Transport Agency, where officials have said they disagree with the coroner’s finding that the braking system is inherently unsafe.
The transport agency views it as safe if used, serviced and tested correctly.
“NZTA has been progressing a range of work following a review in 2025, and we have now integrated additional action into this work programme in response to the two separate coroner’s reports released late last year,” the transport agency’s group manager Mike Hargreaves said.
“Some of the coroner’s recommendations were aligned with what NZTA was already progressing, while other recommendations require extra action.
“In response, we are implementing a comprehensive, practical and evidence-based work programme spanning education, monitoring, compliance and other areas.”
The transport agency would release new warning labels for vehicles with cardan shaft parking brakes, including a QR code linking to safety information.
Hargreaves said a new safety video was being developed, adding to videos on how to correctly service the brakes and how to test them on a roller brake machine.
The agency has also organised free training workshops around the country for technicians and workshop managers.
New Zealand Transport Agency’s group manager Mike Hargreaves. RNZ / Samuel Rillstone
Selwyn Rabbits met with the agency’s director late last year. However, he remains frustrated it doesn’t agree with his and the coroner’s views about the brakes’ dangers, despite her thorough findings.
Selwyn Rabbits realised it was impractical to ban the braking system, in use in tens of thousands of heavy vehicles, but would like to see a halt on imports with cardan shaft parking brakes. So far, this hasn’t happened.
“I’m just so disillusioned with an organisation that says all the right words in terms of ‘every life counts’ and all of that, but is just totally out of touch with the reality.
“It’s almost criminal.”
Coroner’s reports are publicly released and the coroner’s office regularly publishes summaries of recommendations.
Selwyn Rabbits, however, wants to see something more detailed.
“The coroner may publish the findings, but [a role] like the director of NZTA is not answerable to anyone in terms of justifying why they don’t accept them or follow up on them.”
Respond or face fines – victim’s brother
The push for more transparency about responses to recommendations also wins support from Ricky Gray, whose brother Shaun died in the Palmerston North Hospital mental health ward in 2014.
Coroner Matthew Bates found his death was preventable, and he made a slew of recommendations about patient assessments and care, as well as oversight and training of staff.
“I always think, particularly in Shaun’s case, there were a lot of repeat recommendations from previous deaths that are almost a carbon copy to Shaun,” Ricky Gray said.
“Time and time again the coroner’s making these statements, making these recommendations, and they’re either not getting looked at or they’re not even being received by these organisation.”
The coroner’s office has apologised for this in Shaun Gray’s case, when the Medical Council wasn’t informed of recommendations relating to it. Ricky Gray said it was left to him to do this when he followed up on their implementation.
Ricky Gray goes further than Selwyn Rabbits, saying coroners’ recommendations should be enforced, unless an agency can justify not following them.
“I believe that organisations should have to be reporting back to the justice system, to the coroners, and actually explain how they’re implementing these recommendations.
“Yes, there could be fines, in a corporate landscape.”
Not all recommendations are practicable or cost-effective – Minister
Recently retired lawyer Moira Macnab, who is experienced at appearing at inquests, liked the idea of more transparency.
“I think it’s a very good idea because, particularly in health you do, from one hospital to the next, get the same or similar recommendations,” she said.
“Frankly, some of the recommendations ought to have been followed up, but haven’t been.”
She didn’t see the process being too costly.
“I think that you could appoint somebody to go and have a look at a few of these things and go, right, ‘These are the recommendations. I want to check on this. I want to see it’s been taken seriously’.
“I don’t necessarily think you’d have to have a huge organisation to do that. I think if [organisations] were aware they would be followed up on they might be more keen to make changes.”
As well as publishing decisions and recommendations, coroners are required to give organisations or people those recommendations are directed at a chance to comment.
“That process ensures that coroners receive current information about any changes that have been made already, or any obstacles to the implementation of the proposed recommendations or comments, and, in some cases, organisations or individuals suggest alternative ways of achieving the aim of the recommendation or comment proposed,” a spokesperson for the Coroner’s Court said.
“Those responses are taken into account by coroners before they finalise their recommendations or comments.”
Associate Justice Minister Nicole McKee. RNZ / Samuel Rillstone
Associate Justice Minister Nicole McKee said changes to the process about recommendations weren’t on the Justice Ministry’s work programme.
“It is for each agency to determine how it responds to Coroner’s Court recommendations.
“Not all recommendations will be practicable or cost-effective, and there is currently no requirement for them to be.”
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand