The Christchurch mosques inquest: what we know so far

The inquest into the Christchurch mosque massacres has unexpectedly become a source of national shame and embarrassment.

A procession of witnesses has appeared before deputy chief coroner Brigitte Windley with evidence of a confused and chaotic response from police and ambulance services. New Zealand has no reason to feel guilty about the atrocity itself, which was the act of a lone outsider, but the failings of the first responders have come as a shock.

Perhaps the most damning revelation so far is that paramedics took half an hour to enter the Al Noor mosque, apparently because it was St John’s ambulance policy not to enter unsafe scenes.

Several police witnesses told of calling for ambulances, to no avail. One member of the armed offenders squad ran out onto Deans Avenue several times to see why no ambulances were coming. He could see them parked up the road, presumably waiting for the all-clear.

When bystanders asked why no ambulances had arrived, the police officer told them to put the wounded into private cars and rush them to hospital. Think about that: amateurs had to be asked to save lives when skilled professionals were standing by, only a stone’s throw away.

The inquest heard that a wounded survivor, Zekeriya Tuyan, was on his phone to emergency services for half an hour before medical help arrived. Tuyan himself died weeks later.

Eventually a St John’s paramedic entered the mosque knowing he was acting contrary to instructions. “There were human beings inside that needed help,” Dean Brown told the inquest.

Was this an example of the precautionary principle that appears to have taken hold of the bureaucratic mind? The precautionary principle holds that all risk must be mitigated by appropriate safeguards – even, it seems, in emergencies where insistence on following the officially prescribed procedure can be the difference between life and death.

Thank God there are still situations where human initiative, courage and compassion kick in and the rulebook is set aside. Dean Brown was a shining example and so were the helicopter pilots who defied a bureaucratic edict by risking their lives rescuing survivors from Whakaari-White Island – another tragedy that showed by-the-book New Zealand officialdom in a very poor light.

Almost as shockingly, the dead, the dying and the wounded in Christchurch were abandoned altogether for 10 minutes after the police left Al Noor to respond to reports of the second massacre at the Linwood mosque. An AOS member told the survivors that help was on the way, which he assumed to be true. It’s impossible to imagine how they must have felt: dozens dead, others dying, and they were left alone with not even a reassuring voice to comfort them.  

These were the most startling revelations of the inquest so far, but there have been others.  

They included the disclosure that an inexperienced police call-taker who took a 111 call giving advance information about the shootings, from an email sent to Parliament by the perpetrator Brenton Tarrant, treated it as only priority 2. The inquest was told the call-taker may have been influenced by a suggestion from the caller, a parliamentary staff member, that the email was from a nutter.

That call obviously came too late to prevent the slaughter at Al Noor, but it might have given the police time to get to the Linwood mosque before Tarrant struck a second time. A police dispatcher seemed to think so, and that things might have turned out differently if the call had been categorised as priority 1. It will fall to the coroner to decide whether that was a missed chance.

Astonishingly, the police inspector in charge of national communications centres at the time defended the categorisation of the call as priority 2 because it was “general” in nature. In fact it wasn’t; Tarrant’s email was detailed and precise, even identifying the three mosques that he intended terrorising (the third was in Ashburton).

Of course it’s easy to be wise after the event. There was no precedent in New Zealand for the Christchurch mosque massacres. The Royal Commission of Inquiry in 2020 established that they couldn’t have been anticipated. Events unfolded with bewildering speed and police couldn’t be sure at first whether Tarrant had accomplices who might still be at the scene.

Human error in such circumstances is hardly surprising. Only those present at the carnage and its immediate aftermath could know how traumatic and confused it was.

That said, police and emergency services are supposed to be prepared for unexpected and extreme events. That’s the nature of their job. Evidence given at the inquest points to shortcomings, such as a known communication problem between police and St John’s, that were recognised and could have been obviated. The frustration of some witnesses was obvious.

On the upside, we shouldn’t forget that Tarrant was arrested only 19 minutes after the shooting started by two courageous and quick-thinking country cops who happened to be in Christchurch for a training day. Their actions, which thwarted Tarrant’s intention to attack the Ashburton mosque, served as a reminder that for all the benefits of thorough planning and training, there’s sometimes no substitute for intuitive, decisive, on-the-spot action.

But in other respects the response appears to have been almost scandalously shambolic, which may shake New Zealanders’ confidence in the people we rely on to protect human life. Only two weeks into the inquest and with another four to go, it’s already obvious that Windley will have a lot to chew on.

Update (6.15pm): In News First's report of the inquest tonight, the acting paramedic in charge at the scene said police were concerned about the possibility there was an IED (improvised explosive device) at the mosque. He appeared to acknowledge that waiting for the scene to be made safe could have cost lives, but he disputed that the ambulances were "simply stopped" a block from the mosque. He said they were treating victims there. 

"Most trusted" - except, perhaps, by many of their own people

(First published in The Dominion Post, June 2.)

I recently wrote a column in this space about the St John Ambulance organisation. It was prompted by a Consumer survey of emergency survival kits which rated the one marketed by St John as the worst of those tested. Ironically, it didn’t include a first aid kit.

I wondered how an organisation with St John’s proud history and reputation could have exposed itself to such public embarrassment, and I attempted to answer my own question by speculating that it had been corporatised – and in the process, become disconnected from its roots.

I pointed out that it wouldn’t be the only worthy organisation to have succumbed to the ruinous cult of managerialism, with all the attendant trappings of bloated hierarchical structures, marketing and PR flannel, expense accounts and flatulent corporate jargon.

The column prompted a mixed reaction – one predictable, the other unexpected.  I’ll deal with the predictable one first.

Andrew Boyd, St John’s central region general manager, wrote a defensive letter to the paper pointing out, among other things, that a St John first aid kit was available as an extra to the $200 “Emergency Grab Kit”.

This seemed to confirm the suggestion by a disgruntled St John veteran – one of many who contacted me – that the omission of a first aid kit, thus requiring that it be purchased separately, was a calculated commercial decision.

“Profit first!” as one commenter on the Stuff website put it. “St John are more interested in growing the wealth of the organisation.”

As someone else pointed out, the fact that St John sold first aid kits separately was no excuse for not including one in its emergency kit. This person also said you’d assume the kit would include emergency rations and water – but the bright sparks in the St John marketing department apparently didn’t think of that.

Boyd’s letter went on to say that “All St John products are regularly clinically assessed”. Not very rigorously, obviously, or the emergency kit wouldn’t have got such a shellacking from Consumer.

In fact Boyd went on to reveal the kit had been removed from sale while it was “re-evaluated”. What’s that, if not an admission that it was a crock?

But there’s a much bigger issue here, which brings me to the unexpected reaction.

My column uncorked a bottle of disenchantment, cynicism and distrust among the frontline rank and file who represent, for most New Zealanders, the public face of St John. One insider said I had described the organisation “to a T”.

Both in online comments and emails to me directly, St John volunteers expressed dismay at the way the organisation has changed: at the proliferation of middle managers and the layers of sclerotic bureaucracy that get in the way of good people trying to do something they love for the good of the community. These are all hallmarks of corporatisation.

Even more striking was a very real fear that internal critics of the organisation would face repercussions if they were identified. “St John is very touchy about bad publicity,” said one.

That’s another defining characteristic of corporatisation: an obsession with public image and a desperate desire to prevent negative messages getting out. Journalists dealing with corporate communications flunkies see this every day.

Boyd pointed out in his letter that St John was recently voted New Zealand’s Most Trusted Charity in a Reader’s Digest survey, but this didn’t impress one St John stalwart. “He appears to be basking in the ‘most trusted’ reputation when this is actually provided by those of us who work at the coalface – the people who work in the community who the public see and relate to,” this long-serving volunteer wrote in an email.

I received many other comments in a similar vein. One commenter on Stuff said St John had become top-heavy and added: “The petty attitude towards the coalface staff is what gets me. Management think they ARE St John.”

Either the St John hierarchy doesn’t know about this underbelly of discontent, or chooses to ignore it. Either way, something’s wrong.

Is it unfair to single St John out for criticism? Perhaps. Several people named other not-for-profit organisations that have been transformed by corporatisation, and not in a good way. One commenter suggested the problem lies partly with the demands imposed by charities legislation.

Perhaps St John just had the misfortune to come to public attention because of a spectacularly incompetent marketing exercise. But clearly its bosses have some repair work to do. 

St John and the cult of managerialism

(First published in The Dominion Post, May 5.)

I thought it significant that in Consumer’s recent comparison of emergency survival kits on the market, the one that scored worst by far was marketed by the St John Ambulance organisation.

Its “Emergency Grab Kit” got a scathing “fail” from Consumer, with a score of 38% – far below any of the six other kits tested. How humiliating for an organisation that traces its history back to the 12th century, when the Order of Knights of the Hospital of St John of Jerusalem looked after sick and injured pilgrims to the Holy Land.  

What was almost comically ironic was that the St John emergency kit didn’t even include a first-aid kit – this from an organisation that’s synonymous with emergency medical assistance – or food rations. And to make matters worse, the pack wasn’t cheap ($200 compared with one at $85 and another that costs $139).

In a sense, it’s a betrayal. People buying an emergency kit bearing the name of St John are entitled to expect that it will set the standard for all others. In fact it appears the reverse was true.

You have to ask: how could an organisation with St John’s proud record end up in such a state?

Let me hazard a guess. It’s been corporatised.

What typically happens is this. Organisations like St John start out as voluntary. They are run on the smell of an oily rag by enthusiastic, committed amateurs whose only reward is the satisfaction that comes from doing good for the community.

No doubt that’s still true at the grassroots level. But what happens as such organisations grow is that they reach a point where enthusiastic amateurism no longer cuts it at the top level. They evolve into bureaucracies.

They adopt all the trappings of the private sector. They acquire a flash office in Wellington and they hire professional managers, public relations consultants, fundraisers, marketers, website designers, health and safety trainers and HR advisers.  They also recruit university-educated careerists whose lack of life experience doesn’t stop them from wanting to re-invent the wheel.

In other words they get corporatised. With this come expense accounts, corporate credit cards, business-class travel and company cars. Along the way, the purity of purpose that originally motivated them tends to get diluted.

They also get contaminated by the deathly cult of managerialism, with its key performance indicators, meetings, values statements, general control freakery, risk avoidance, more meetings, arse-covering, preposterous jargon, more meetings and bitchy office politics.

Of course an organisation as large and complex as St John requires an appropriate management structure. The danger is that as these organisations grow bigger and more unwieldy, they became so pre-occupied with the minutiae of management that they lose sight of their core functions. Management becomes an end in itself.

If they are partly funded by the state, as many are, things get more complicated, because government bureaucrats create hoops for them to jump through. So they hire more people to ensure compliance with the government’s requirements – which might include, for instance, paying someone to come up with Maori names for everything they do, even though no one ever uses them.

Under the headline Vision and Values on the St John website, for example, you see things like: “We Make It Better – Whakawerohia. We find solutions – step up, own it, do it.”

There it is, right there: management psycho-babble that means whatever you want it to mean.

All this, needless to say, gobbles up money that might otherwise be used for whatever purpose the organisation nominally exists for.

In the meantime, the faithful and tireless people at the grassroots go on doing what they have always done. But the corporate head office grows gradually more distant and disconnected from its original ethos, and the people at the grassroots feel powerless to influence decisions and policy.

I’m not saying this has happened at St John, but it has certainly happened to other organisations in the not-for-profit sector – for example the IHC, a $280 million-a-year behemoth whose head office sometimes gives the impression of being unaccountable to faithful, long-serving members.

Some would say New Zealand Rugby has gone down a similar path, moving ever further from the game’s muddy amateur roots.

Is the same true of St John? I admit I can’t be sure, but the fact that the organisation couldn’t put together a basic emergency kit – or worse still, perhaps couldn’t be bothered – suggests it may have lost sight of what most of us assumed it existed for.