Serious failings and under-resourcing in the coronial system are stopping coroners from preventing further deaths, research has found.
Some coroners feel their recommendations have been falling on deaf ears, according to an Otago University study that looked at more than 600 coroners’ reports.
That’s because so many of their recommendations are daft and impractical.
The failings were evident in the high number of repeated recommendations, particularly in cases of drowning, sudden unexplained infant deaths, and transport accidents.
Research author Jennifer Moore said she wanted the law changed to make the system more effective, but it was unlikely the Government would budge.
About 72 recommendations were vaguely directed, and she believed there should be a mandatory response system in place.
The non silly ones do tend to get a response, but the problem is too many coroners come up with recommendations that are unbalanced. Their aim is to recommend ways to reduce deaths, which is of course a good thing. But some never seem to consider practicality or compliance costs, let alone freedom of choice to do stupid things.
There should also be additional support, training and resources available for coroners, she said.
Coroners did not receive training from a judicial institute, which she said would improve the quality of recommendations. The 17 coroners did not have books with decades of full decisions to refer to, and had to share two assistants.
Now that I would support.
Chief coroner Neil MacLean said the research was a valuable, objective point of view. “We’re already taking on board some of the criticism and I hope the Government will listen to their recommendations.”
Under-resourcing was a particular day-to-day frustration, he said. One of the most effective changes would be making it mandatory for agencies to respond to recommendations directed at them. “The thing about having a rigorous, transparent, mandatory response system is that we can be assured of feedback. We accept that some of the recommendations we make are unbalanced or miscued or directed at the wrong people – we need to know that, so we can do better next time.”
That’s a fair point. The Chief Coroner is, in my opinion, excellent. What I’d rather do is institute better resourcing and training, and then after that review if mandatory responses are a good idea.