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 5: The promise of saved lives: coroners’ preventive function

Jennifer Moore

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


In the previous chapter I outlined the argument that the preventive potential of coronial recommendations is undermined when recommendations are not implemented by organisations. This chapter explores coroners’ preventive function in detail and, in particular, the following questions: • Do coroners’ recommendations save lives? • What counts as a “successful” coroner’s recommendation? Is success measured by the number of lives saved and/or evidence of the uptake of recommendations by organisations? • How can we maximise the preventive potential of coroners’ recommendations? NZ coroners have been described as “public health officials” because of their statutory preventive functions. The principal role of coroners is to investigate and determine causes of deaths that occur in sudden, unexpected or unnatural circumstances. This work advances public health indirectly, not least by enhancing the quality of vital statistics and public health surveillance. Some coronial data is shared with other injury and death prevention agencies in NZ and overseas. In some jurisdictions, such as NZ, Australia, Ireland, the UK and most Canadian provinces, coroners are also vested with authority to play a more direct role in advancing public health. As part of their findings, they may issue recommendations aimed at reducing risk and improving health and safety in the community.

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