Lives could be saved if suggestions by a University of Otago study into coroners' recommendations were acted on, the chief coroner says.
Lead researcher Dr Jennifer Moore, from Otago's law faculty, and fellow Otago researcher Mark Henaghan are arguing for the introduction of a mandatory statutory regime to ensure coroners' recommendations are followed through.
They said more resources, training and support for coroners was needed, and supported a system of compiling coroners' law reports be introduced, enabling better tracking of similar cases.
Chief coroner Neil MacLean said making it mandatory for coroner's recommendations to be acted on could save lives and provide solutions for ''endemic'' problems.
''It removes the possibility that [recommendations] just disappear into a black hole, either because the people didn't get them or they didn't go to the right part of an organisation.''
It would also provide coroners with feedback when they got it wrong or when there was other information coroners needed to be aware of.
He applauded the university for doing the study and was looking forward to seeing the full report.
''I think it's an astounding piece of work and they are to be complimented.''
Dr Moore said the measures would improve the quality of coroners' recommendations.
''The study findings suggest that although some coroners' recommendations contribute to positive health and safety outcomes, many recommendations are not fulfilling their potential to identify and promote opportunities to prevent deaths,'' she said.
The study, funded by the New Zealand Law Foundation, reviewed all coroners' recommendations in the five years to June 2012, and was the most thorough analysis of coronial findings.
Dr Moore conducted 102 interviews with coroners, public and private organisations that were sent coronial recommendations, and interested parties.
The researchers were surprised to find there were only two researchers to assist 17 coroners, and that no official coroner's court law reports, which would enable coroners to compare cases, were compiled.
A final report will be released next year.
