The Coroner has called investigations into the death of preschooler Lachie Jones, found dead in an oxidation pond near Gore, “a shambles”.
Coroner Alexander Ho has instructed police to investigate the case for a third time – recommending “an experienced officer” from outside of Southland.
Three-year-old Lachie Jones was found dead, more than a kilometre from his mother’s home and floating face up, on the evening of January 29, 2019.
Coroner Alexander Ho spent five weeks at the Invercargill courthouse to held an inquest into the toddler’s death, over two separate phases last year, which finished in August last year.
Two police investigations found he accidentally drowned, running away from his mother and falling in, but Lachie’s father Paul Jones has continued to dispute those findings.
Today, Coroner Ho delivered his 160-page report, and said “I am not convinced that we have heard the entire truth about the events of 29 January 2019.”
He said: “there is an indubitable impression of transgressions in various aspects” and “the conduct of the subsequent police and medical investigations into this death have compromised my ability to make findings”.
“Bluntly, it is difficult to escape the lingering impression that much of what occurred was a shambles which could, and should, have been avoided.”
Coroner Ho heard evidence from family and friends, emergency services, and from expert witnesses.
The findings were delivered under embargo in Invercargill today, three weeks after what would have been Lachie’s 10th birthday.
“Accident or something sinister, that is the central question which lingers over the death of Lachie Jones.”
Among the police deficiencies, Coroner Ho said “there was confusion about the identity of the officer in charge in the first investigation.
“There were frankly astonishing scenes at inquest of two senior police officers each disclaiming responsibility for leading the investigation,”
“It did not bode well for the quality of the investigation that no one could tell me who was actually in control.”
He said one of the officers went on scheduled leave in the initial stages of the first investigation and “there appeared to be a lack of urgency in progressing matters”.
Ho said today: “I am not satisfied that the evidence establishes the police’s conclusion that Lachie died by accidental drowning after running away”.
He said Lachie’s mother Michelle Officer’s statement “was signed ten days after Lachie died and Jonathan’s statement [her older son] is dated over a month after Lachie’s death. Some witnesses were not interviewed until the police re-investigation almost two years later, and others not until the inquest.”
Ho concluded “I am not satisfied that Ms Officer’s testimony can be accepted in its entirety”.
He said this was partly due to police decisions – “There also appears to have been a view, formed early in the initial investigation… of preferring Ms Officer’s account of events even though it had not been rigorously tested.”
And he said: “The delays came from the police’s early conclusion in the first investigation that this was an explained accidental drowning meant that they did not approach the witness evidence phase with the rigour that I would have expected.”
Ho acknowledged some family, “do not believe that a young child would at 9pm after a long day, run such a long distance, barefoot in a soiled nappy, down a gravel road and scale a wooden fence to a place he had apparently not been before. They do not believe that Lachie came to be in the water from his own actions. They think that there were others involved or complicit in his death.”
He added that “there is merit in the police again investigating Lachie’s death. It is ultimately an operational matter for the police to determine how and by whom any re-investigation should be conducted. However, had I the power to do so, I would require that any re-investigation be led by an experienced officer from outside Southland district. It would be beneficial for a fresh lens to be applied to the investigation and any conflicts of interest minimised.”
He strongly urged anyone “who has, or thinks they may have, further information about the events of 29 January 2019 to contact the police”.
“I do not accept that the police investigations correctly outline what occurred that evening. Indeed, I have found in many instances that the evidence does not support the propositions which the police presented as concluded fact.”
But he said police recently gathered more evidence on the location of some cell phone use, in response to draft coronial findings released to them, and this data could be used in future investigations.
The Independent Police Conduct Authority (IPCA) concluded in an earlier report that investigations adequately addressed matters and the IPCA did not take the matter further.
But Ho said: “I consider it is appropriate to refer to the IPCA the police’s conduct as it relates to the investigations which have been conducted to date into Lachie’s death.”
Ho’s strongest criticisms of the medical investigations were due to Lachie’s head not being examined closely in the post-mortem.
“Contrary to the duty coroner’s written direction for a full three-cavity post-mortem examination, [the pathologist] opened only Lachie’s chest and abdomen” and “did not open the head.”
“The examination and report were not completed to the standard which would allow me to safely rely on their contents.”
He instructed: “The police are to provide a report to the responsible coroner on or before 16 January 2026.
“These findings are to be provided to the IPCA. These findings are to be provided to the New Zealand Medical Council.”
Police respond to coroner’s findings
Assistant Commissioner Mike Johnson said police would need to consider the findings and the direction by the coroner to undertake a third investigation.
“We will work diligently on all aspects we need to undertake to progress that with the appropriate resources and urgency to complete this direction as is required,” he said.
Johnson said police wanted “to acknowledge Lachie’s family and the impact his death and the subsequent processes have had on them”.
“Police would also like to take this opportunity to recognise members of the public who came out on the evening Lachie was reported missing and searched for hours. We know that Lachie’s death has also had an impact on them and the wider Gore community.
“Police have previously acknowledged but reiterate again today that our initial action following Lachie’s death fell short of the high expectations we set for ourselves. As a result of Lachie’s death, police have implemented a national policy change which requires that CIB must be consulted for any death of a baby, child, or young person and where possible attend all scenes. The CIB will also be required to oversee or lead any investigation into the death of an infant or child under 10.
“Our deepest thoughts and sympathies continue to be with Lachie’s family.”
