Failings put lives at risk

Jennifer Moore
Jennifer Moore
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 earlier judgements.

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 prevention measures.

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 coroners.

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 to organisations.

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'', she said.

''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.
• Repeated recommendations included drownings (201), sudden unexpected deaths in infants (47) and transport-related accidents (58).
• Coroners felt repeated recommendations were not being implemented.

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