Chapter 6: Mandatory responses to coroners’ recommendations
The former NZ Chief Coroner has expressed the view that a mandatory statutory regime for follow-up to coroners’ recommendations should be introduced. Such a mandatory response regime requires meaningful responses from those entities to which coroners have made recommendations. Those entities need to indicate either how they would implement recommendations, or the reasons why implementation would not take place. Many NZ coroners feel a deep sense of frustration that their preventive recommendations are not being heeded, contributing to otherwise preventable deaths. Family members of deceased persons also feel frustration that their loved ones’ deaths are not making as great a difference in saving lives as they could. The preventive potential of coroners’ recommendations could be maximised during and after the death investigation process. In Chapter 5, I considered how consultation with agencies and experts during the death investigation could improve coroners’ recommendations and, thereby, strengthen the preventive potential of coroners’ recommendations.
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