Presented at the 11th Annual Medical Law Conference - April
2010.

Introduction

The Coroners’ Act
2006 drew substantially on the recommendations made in the Law Commission
Report No 62 “Coroners” (August 2000).

In some areas Parliament
eventually went much further by abolishing the old system completely and
starting afresh with new fulltime Coroners who now must have Legal qualifications
as well as adding a Chief Coroner.

In other areas Parliament
decided to back away from some of the Report’s proposals, such as:

• Recommendation
  12 : Notice to be given by the Chief
  Coroner of a coronial recommendation to a relevant agency or person before the
  recommendation is publicly released.

• Recommendation
  13 : Production of an Annual Report from
  the Office of the Chief Coroner summarising recommendations.

• Recommendation
  14 : Reporting by a government agency to
  its Minister with 3 months with regard to any coronial recommendation which
  concerns that government agency

 

What Actually Happened About
Coroner’s Recommendations?

A  provision was made to continue the practice of
Coroners making recommendations but the responsibility for ensuring they were
drawn to the attention of the right people was left to the individual Coroner.

So What Did We Get?

A website to
which a synopsis of relevant findings prepared under the supervision of the
Chief Coroner are posted:

http://www.justice.govt.nz/courts/coroners-court/recommendations-register-data

To date, there
are 133 recommendations on that database covering the period from 1 July 2007
to the present time and there are several broad themes emerging.

Generally, there
is often a response to these and a summary of any  response is posted on the website.

In contrast, Victoria has a mandatory requirement for public
statutory authorities & entities to provide a written response to the
recommendations (specifying any action taken/to be taken) within 3 months of receipt
of the recommendations which the Coroner must also publish on the internet and
provide to certain persons with interest.

The new England
& Wales Coroners’ Act does not discuss Recommendations and the only
provision that they have is under Coroners Rules 1984 (Rule 43) where a Coroner
may announce at an Inquest that he is reporting a matter in writing to a person
or authority who may have power to take action to prevent the recurrence of
similar fatalities and may report the matter accordingly.

Has It Made Any Difference?

It will take some
time to see whether consistent repeated recommendations and/or comments make a
difference - e.g. with Sudden Infant Death Syndrome regarding safe sleeping
practices.

Could The Coronial Service Unit Do
More?

Many Coroners are
taking up the opportunity to present and talk to a range of community groups
and this complements the Recommendations process.

Issues Around Exchange Of
Information With Other Agencies

Inter-agency
co-operation is very much part of the spirit of the new legislation and there
are very powerful moral and ethical imperatives to provide mortality data to
other agencies to help raise awareness and to prevent deaths to the betterment
of the public.

Coroners, as in
the case of all judicial officers cannot be made to supply information.  We need to balance the fair and timely access
to coronial information with having to act with integrity as guardians of
intensely private and sensitive information and to ensure the validity of the
information.

Once a Coroner’s
file is closed the information is sent to the Ministry of Justice for archiving
at which point, subject to OIA or Privacy Act, any person can access information
other than Judicial notes.

The Australian
National Coronial Information System is shortly to be joined by New Zealand.