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 3: Coroners’ recommendations

Jennifer Moore

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


In Chapter 1, and elsewhere, I have described the limitations of coronial data sources and the difficulties in accessing complete datasets of full coroners’ findings. In several jurisdictions abroad, government organisations compile basic statistics about Coroner’s Courts and coronial recommendations. Despite the introduction of the Recommendations Recap, a common complaint during interviews was that the shortcomings in access to publicly available full findings in NZ have meant that it has been difficult to compile accurate statistics about coronial findings. This chapter attempts to address some of these problems by providing descriptive quantifications of NZ coronial recommendations during the study period. The results and discussion in this chapter address my research objective to describe the nature, frequency and recipients of NZ coroners’ recommendations, 1 July 2007 – 30 June 2012.

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