Editorial: Coroners must be heeded

Coroners have for years been sending out the same messages but it seems very little ever comes of their recommendations.

Under the New Zealand system recommendations do not have to be followed through.

For several decades now coroners have warned about the dangers of children and quadbikes; they have warned ad nauseam about the dangers of adults sleeping with infants; they have urged officials to run campaigns and consider legislation changes to try to reduce the incidence of "avoidable" deaths.

How often are these recommendations and warnings acted upon? Not too often, it would seem. Our local coroner, Wallace Bain, some time ago called for a national campaign regarding safe sleeping practices after yet another "roll-over" death of an infant sharing a bed with an adult. The first thing that needs to be overcome in regards to this particular issue is inconsistency in the messages women get.

On the one hand midwives and other advisers are encouraging them to sleep with their babies while on the other, coroners are telling them this is a recipe for tragedy.

What is the point of having a coronial system if coroners' warnings and recommendations go largely unheeded? What is the point of putting families through the added grief of an inquest and spending taxpayer money on investigations and hearings when the outcomes can simply be ignored?

Unnecessary, preventable deaths continue to occur, the same factors continue to arise and the same recommendations continue to be made by coroners _ but little changes.

New Zealand's Chief Coroner, Neil MacLean, wants our coronial system to be more like that of Victoria in Australia which has a group dedicated to collecting information about the response to and implementation of coronial recommendations.

There's a research project about to begin to consider if our Coronial service is achieving its full potential in public health prevention. On the face of it, we can guess what it will find.