You are not permitted to download, save or email this image. Visit image gallery to purchase the image.
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 added.
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 adopted.
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 service.
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.''