Hundreds more lives can be saved if ''serious failings''
in the New Zealand coronial system are addressed, including by
boosting resources, improving information sharing and changing
the law, a Dunedin academic says.
Dr Jennifer Moore, the main author of a University of Otago
study into the coronial system, said a systemic lack of
resources and other problems meant that one of the main
purposes of the coroners legislation - to help prevent future
deaths - was being undermined.
''They definitely need more resources,'' she said yesterday.'
Such resources included additional researchers, information
sharing systems and better access to full coronial judgements
and decisions, enabling coroners to review more easily
The country's 16 coroners were supported by only two
researchers, a clear example of the insufficient resources.
The New Zealand public deserved a highly performing coronial
service to highlight avoidable deaths and recommend
Coroners sought to make ''quality preventive
recommendations'' but resource constraints and other problems
meant ''with the best will in the world, it's really
difficult for them to do that''.
The Otago study of more than 600 findings by coroners in New
Zealand identified failings that constrained the ability of
coroners to act preventively and stop further loss of life.
Dr Moore, acting director of the Legal Issues Centre at the
Faculty of Law, urged further legal changes, including
introducing mandatory reporting for organisations receiving
coroners' recommendations, and more training support for
The reporting provision would require organisations to which
coroners had made a recommendation to make a formal written
response saying what, if anything, they proposed to do.
The study of 607 coronial inquiries during the five years
from July 2007 to June 2012 is published in the New Zealand
Medical Journal today. This was the first major study into
New Zealand coronial findings. The research was funded by a
$137,861 grant from the New Zealand Law Foundation.
The main finding of the research, which also included 123
interviews with coroners, and public and private
organisations sent coroners' recommendations, was that the
preventive and patient safety potential of coroners'
recommendations was not being maximised, due to serious
systemic issues and under-resourcing.
New Zealand could learn from the Melbourne-based Victoria
Coroners Court. It was supported by a specialised and
well-resourced Coroners Prevention Unit, which helped with
several aspects of coronial work, including research.
New Zealand families hoped that when a loved one died,
lessons would be learnt, through the coronial system, which
would help prevent further needless deaths.
However, that hopeful vision was not being fully realised,
for many reasons, including that some coronial
recommendations were not being taken up, and there was often
a lack of transparency about the outcome of recommendations
Some coroners' recommendations were ''success stories, that
have had a positive impact''.
One such example was a recommendation by Wellington regional
coroner Garry Evans in 2001 to install a median barrier on
the Centennial Highway near Wellington, after eight deaths in
about a year. Since the recommendation was implemented in
2004, an estimated 50 lives had been saved. Improving the
coronial system would reflect ''what the community wants'',
''Families who have lost a loved one to a preventable death,
they want that life to have a meaning.
''They want the coroner's recommendation to have an effect
[to prevent other deaths],'' she said.
There was considerable frustration within the system that
significant recommendations were not being implemented.
There was also a need for coroners to receive specialised
training, of the kind already offered to judges.
NZ coronial system
Study of 607 coronial findings. -
• Of 1644 recommendations, 324 were identical and
• Repeated recommendations included drownings (201), sudden
unexpected deaths in infants (47) and transport-related
• Coroners felt repeated recommendations were not being