The chief coroner would like it to become mandatory for coroners' recommendations to be responded to.
Speaking on TVNZ's Q+A programme this morning, Judge Neil MacLean said people's lives were being lost because the recommendations were too often ignored.
"One step that I have cautiously pushed is to follow what the Brits do, what some of the Australian jurisdictions now do, and actually make it mandatory, compulsory, to respond to a coroner's recommendation.
"At the moment, our recommendations sort of can easily, so to speak, die in the ditch, because they go out there, they sit there, they're never actioned.''
Judge MacLean said cyber bullying, youth suicide and drug abuse were constant themes confronting coroners.