Former Dunedin coroner Jim Conradson believes
organisations sent a coroner's recommendation should have to
reply in writing, stating what action they will take.
Mr Conradson, who served as coroner for more than 30 years,
said families who had lost a loved one hoped reasonable steps
would be taken to avoid similar preventable deaths in future.
Making a law change to require organisations, including
government agencies, to reply in writing would help meet that
goal, he said in an interview.
Such organisations could say: ''Yes, we'll do it'' or ''We
can't do it yet, there's no money'' but it was ''important''
that they replied.
As coroner (1971 to 2003) he did not have the feeling that
his safety-oriented recommendations were being ignored, he
Dr Jennifer Moore was the lead researcher in a recently
published major study which highlighted ''serious
shortcomings'', particularly insufficient resources, in the
New Zealand coronial system.
Dr Moore, who is the acting head of the Legal Issues Centre
at the University of Otago Law Faculty, also advocated the
introduction of ''mandatory reporting''.
Mandatory reporting requires organisations, including
district health boards, to reply in writing after they
receive a coronial recommendation.
The first major study into New Zealand coronial findings was
based on research funded by a $137,861 grant from the New
Zealand Law Foundation.
This study, published late last week in the New Zealand
Medical Journal, drew attention to repeated identical
recommendations, including unexpected sudden deaths in
infants (47) and transport-related accidents (58).
Dr Moore said there was some frustration within the New
Zealand coronial system that some recommendations were not
More lives would be saved if New Zealand followed the example
of Victoria, Australia, by introducing ''mandatory
reporting'' and providing more support for the coronial
She noted that Victoria, Australia and England had such
provisions in their law, requiring organisations to reply,
stating ''what, if anything, they propose to do, and why''.
''It is working well in Australia. It is not a radical idea
and would not represent an unreasonable extra cost.''