Coroners' Recommendations and the Promise of Saved Lives

Coroners' Recommendations and the Promise of Saved Lives

Jennifer Moore

This is the first empirical law book to investigate coroners’ recommendations, and the extent of their impact and implementation. Based on an extensive study, the book analyses over 2000 New Zealand Coroners’ recommendations and includes more than 100 interviews and over 40 respondents to a survey, as well as Coroner’s Court findings and litigation from Canada, England, Ireland, Australia and Scotland. This timely book is an overdue investigation of the highly debated questions: do coroners’ recommendations save lives and how often are they implemented?

Chapter 1: Learning from death

Jennifer Moore

Subjects: law - academic, constitutional and administrative law, health law, law and society, social policy and sociology, health policy and economics

Extract

In February 2011, in a New Zealand (NZ) coronial inquiry that attracted widespread media attention, Robert Barlow, father of the deceased bay, Adam, explained. We don't want our son to be remembered as the baby who died at the hands of a flawed maternity system. We want him to be remembered as the baby who brought about positive change in the maternity sector for the good of future mothers and babies. Coroner Matenga found that baby Adam died after a "series of failures" by the midwife contributed to a hypoxic intrauterine environment during a prolonged stage of labour due to foetal malposition.