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Otago law researchers suggest changes to improve Coroners’ recommendations


Monday 5 August 2013 3:25pm

Many Coroners’ recommendations are not fulfilling their potential to identify and promote opportunities to prevent avoidable deaths, the first such study ever of New Zealand Coroners’ recommendations has found.

Preliminary findings of the ground-breaking University of Otago study indicate that some Coroners’ recommendations are contributing to positive health and safety outcomes, but many are not.

Lead researcher Dr Jennifer Moore from Otago’s Faculty of Law says this may result in lost opportunities to save New Zealanders’ lives.

Otago researchers Professor Mark Henaghan and Dr Jennifer Moore

Dr Moore and fellow Otago researcher Professor Mark Henaghan found that all Coroners and all but two of the 79 organisations interviewed support the introduction of a new mandatory statutory regime for follow-up of Coroners’ recommendations, provided that additional changes are made to coronial services.

The researchers argue that more resources, training and support for Coroners is needed, and that a new system of compiling Coroners’ law reports be introduced, enabling better tracking of similar cases.

Such measures would improve the quality of Coroners’ recommendations and result in the more consistent application of prevention principles and scientific evidence.

The study, funded by the New Zealand Law Foundation, reviewed all Coroners’ recommendations in the five years to June 2012, representing the first and most in-depth analysis of coronial findings.


Dr Moore also conducted 102 interviews with Coroners, public and private organisations that are sent coronial recommendations, and interested parties.

“Given the high public profile of Coroners and the importance of their work, it is surprising that there has been limited investigation of Coroners’ decision-making. The study findings suggest that although some Coroners’ recommendations contribute to positive health and safety outcomes, many recommendations are not fulfilling their potential to identify and promote opportunities to prevent deaths,” she says.

Sudden unexpected death in infancy is an example of Coroners collaborating with agencies and experts that works to produce preventive recommendations with important health and safety messages. Dr Moore says while it is often claimed that Coroners’ recommendations are not acted on, the study suggests most organisations do consider and respond to their recommendations, and there may be reasonable explanations for not taking action.

However, the researchers were surprised to find there were only two researchers to assist 17 Coroners, and that no official Coroner’s Court Law Reports are compiled. These reports would enable Coroners to consider similar cases in the past.

“Without official law reports, it is difficult for lawyers and Coroners to do their jobs, and the consistency of Coroners' decision-making and recommendations is impacted,” she says.

“For example, if a Coroner is investigating a jet skiing death, she or he may wish to consider all previous cases involving such deaths for the last 20 years. What have other Coroners said about such deaths? What recommendations, if any, were made? What were the issues? It is difficult to undertake this work without access to official law reports which record the cases and recommendations.”

The project is being undertaken in collaboration with the Coronial Services of New Zealand to inform Coroners’ practice in light of the research findings. The research could inform the current Ministerial review of coronial services and the debate about what law reform and operational changes are required.

The researchers have taken account of overseas experience and say that the approaches of the Coroner’s Court of Victoria, Australia, could be used as a model.
Dr Moore says the New Zealand public deserves a highly-performing coronial service to highlight avoidable deaths and recommend prevention measures.

“There have been improvements since the last review of coronial jurisdiction in the early 2000s, but more is needed,” she says.

“Several of the Minister for Courts’ recently-announced proposals for law reform are positive, but our research suggests that the Government’s proposed changes are unlikely to maximise the full preventive potential of Coroners’ recommendations.”

There are approximately 29,000 deaths in NZ each year, of which about 20 percent are reported to Coroners. Most years there are approximately 1,334 inquests resulting in 212 Coroners’ recommendations.

A final report outlining all the study’s results will be released next year.

For further information, contact

Dr Jennifer Moore
University of Otago
Faculty of Law
Mob 64 21 259 5661
Tel 64 4 383 6456

Professor Mark Henaghan
Dean of Law
Faculty of Law
University of Otago
New Zealand
Tel 64 3 479 8856

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