Coroners' Recommendations and the Promise of Saved Lives
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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?
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Chapter 4: Do coroners’ recommendations “disappear into a black hole”?

Jennifer Moore


Part of me says that generally our recommendations are being implemented. But I think that until you’ve done your analysis, we won’t know for sure. It will be the first time that we will have any sort of handle on the extent that coroners’ recommendations are implemented. I don’t hear why our recommendations are implemented when they are. I don’t often hear why they are not implemented either. Sometimes we will get a blunt letter back saying that the agency has the recommendation, but in polite language, they think that it is daft and they say that the coroners have not seen the broader picture because we have just focused on one particular case. . . Other than that we don’t hear anything about why recommendations are not implemented. That is, until the same thing happens another time. Then questions get asked like “well what did happen? Coroner X recommended this to you. What did you do? I see seven other coroners said the same thing and the Department still has not done anything. Why is that?” A classic example of that is prisoners hanging themselves. We asked why nothing had been done and the Department said that they knew the building was going to be demolished so there was not much point doing anything. But in the meantime half a dozen prisoners hanged themselves. This is one of only two studies in the world to examine organisations’ responses to, and implementation of, coroners’ recommendations. As the former NZ Chief Coroner points out, this research is “the first time that we will have any sort of handle on the extent that coroners’ recommendations are implemented”. Coroners receive limited feedback about organisations’ responses to their recommendations. Apart from occasional “blunt letters”, the extent of implementation of coronial recommendations is suggested when repeat fatalities occur, such as prisoners hanging themselves. Since October 2011, any responses that the CSNZ receives from organisations have been published in Recommendations Recap.

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