"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," says Dr Moore.
The study, funded by the New Zealand Law Foundation, reviewed all coroners' recommendations in the five years to June 2012, representing the first and most in-depth analysis of coronial findings.
Dr Moore also conducted 102 interviews with coroners, public and private organisations that are sent coronial recommendations, and interested parties.
"Given the high public profile of coroners and the importance of their work, it is surprising that there has been limited investigation of coroners' decision-making," she said.
Sudden unexpected death in infancy is an example of coroners collaborating with agencies and experts that works to produce preventive recommendations with important health and safety messages, says the researchers.
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 consider similar case, are compiled.
"Without official law reports, it is difficult for lawyers and coroners to do their jobs, and the consistency of coroners' decision-making and recommendations is impacted," Dr Moore said.
"For example, if a coroner is investigating a jet skiing death, she or he may wish to consider all previous cases involving such deaths for the last 20 years. What have other coroners said about such deaths? What recommendations, if any, were made? What were the issues?
"It is difficult to undertake this work without access to official law reports which record the cases and recommendations."
The project, undertaken in collaboration with the Coronial Services of New Zealand, could inform the current Ministerial review of coronial services and the debate about what law reform and operational changes are required. A final report outlining all the study's results will be released next year.
There are approximately 29,000 deaths in New Zealand each year, of which about 20 per cent are reported to coroners. Most years, there are approximately 1,334 inquests resulting in 212 coroners' recommendations.