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 6: Mandatory responses to coroners’ recommendations

Jennifer Moore


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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