A coroner has recommended a third police investigation into the death of 3-year-old Lachie Jones, who drowned in an oxidation pond in Gore in 2019. Coroner Alan Smith found that the initial police and medical investigations were inadequate and did not meet professional standards. The coroner highlighted significant issues with the post-mortem report, the lack of a thorough examination of Lachie’s head, and the overall conduct of the investigations, which compromised his ability to determine the exact cause of death. ### Key Findings: - **Drowning Diagnosis in Question**: The coroner noted that the initial post-mortem was of poor quality and could not be relied upon. He concluded that while the evidence supported a drowning diagnosis, it was not conclusive. Other possibilities included drowning secondary to head trauma or fatal head trauma. None of these crossed the balance of probabilities threshold. - **Lack of Supervision**: The coroner found that Lachie may have slipped away in a brief moment of inattention from his mother, Michelle Officer. Several witnesses reported seeing him running down Salford Street before he was found in the pond. - **Inadequate Police and Medical Response**: The coroner criticized the initial investigations for falling short of professional standards. He noted that the presence of foam around Lachie’s mouth, which was cited as evidence of drowning, could also result from other causes, including head trauma or post-mortem fluid aspiration. The lack of a thorough head examination left the possibility of fatal head trauma unresolved. - **Need for Further Investigation**: The coroner recommended that a third investigation be conducted by metropolitan police from Auckland, ideally under the oversight of the Police Commissioner. He emphasized the need for accountability and transparency to restore public trust in the police force. ### Reactions: - **Lachie’s Father**: Paul Jones, Lachie’s father, expressed relief at the coroner’s findings and called for a thorough reinvestigation. He stated, “If the police are to move forward in this country and have credibility, they must have accountability. I expect to hear from them now.” - **Lachie’s Mother**: Michelle Officer’s council, Beatrix Woodhouse, stated that Officer welcomed the findings but expressed concern over the adversarial nature of the coronial process. Woodhouse noted that Michelle had remained steadfast in her account and now wishes to grieve privately. - **Police Response**: Assistant Commissioner Mike Johnson said Police would consider the coroner’s findings and work diligently to complete the required investigation. He acknowledged that the initial response to Lachie’s death fell short of expectations and noted that national policy changes had been implemented to improve the handling of similar cases. ### What Now?: - **Next Steps**: The coroner has left the inquest open pending the outcome of the recommended police reinvestigation. Police are directed to update the court on their progress by January 16, 2025. - **Impact on Public Trust**: The case has raised concerns about the adequacy of police and medical responses to child deaths in New Zealand. The coroner’s findings underscore the need for improved protocols and accountability to prevent similar incidents in the future. ### Conclusion: The death of Lachie Jones has exposed significant flaws in the police and medical responses to child deaths in New Zealand. The coroner’s recommendation for a third investigation reflects the need for a thorough and transparent process to determine the truth and restore public confidence. The case serves as a reminder of the importance of rigorous investigations and the need for continuous improvement in handling sensitive cases involving children.