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 7: Dying for change

Jennifer Moore

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


This scene from the movie The Wizard of Oz depicts the citizens of Oz appealing to coronial expertise. After examination of the crushed body of the Wicked Witch of the East, the coroner confirms for the public her untimely accidental death. The coroner officially declares her dead with the production of an oversized “Certificate of Death”: “Ding dong, the Witch is dead. . .” The duties of modern NZ, Australian or English coroners no longer include examination of the deceased. Despite their “shape-shifting” roles throughout history, the coroner continues to play an important role in investigating and certifying sudden, violent and unnatural deaths. An important purpose of an inquest is to establish that a person has in fact died (or, is “spiritually, physically, positively, absolutely, undeniably and reliably dead”). The state is interested in ascertaining the causes of deaths in order to prevent similar deaths from occurring in the future.

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