Coroners' recommendations about healthcare-related deaths as a potential tool for improving patient safety and quality of care

N Z Med J. 2014 Jul 18;127(1398):35-53.


Aims: To describe and investigate the nature, recipients and preventive potential of New Zealand coroners' recommendations from 1 July 2007-30 June 2012.

Method: (1) A retrospective study of coroners' recommendations during the study period was undertaken. (2) Interviews with coroners, recipients of recommendations and interested parties were conducted.

Results: There were 607 coronial inquiries that resulted in 1644 recommendations. There were 309 recipients of coroners' recommendations. Government organisations received the highest proportion of recommendations (121/309). Not for profit organisations received 67 recommendations, for profit organisations received 44 recommendations and individuals received 5 recommendations. There were 72 untargeted recommendations that did not specify an identifiable organisation. The Ministry of Health received the second-highest proportion of coroners' recommendations. Transport accidents, drowning, intentional self-harm and complications of medical or surgical care were the main underlying causes of death categories investigated by coroners. Fifty-eight of the 607 inquiries involved complications of medical or surgical care. The 123 interview participants reported that there have been improvements in coronial recommendations since the introduction of the Coroners Act 2006, but that the prophylactic and patient safety potential of recommendations is not being maximised.

Conclusion: Coronial investigations provide external insight into the way that our health system works and recommendations can be used as a tool to learn from preventable deaths. Given that this was the first New Zealand study of coroners' recommendations since the introduction of the Act, more research is needed to corroborate these findings.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cause of Death*
  • Coroners and Medical Examiners*
  • Humans
  • Medical Errors / legislation & jurisprudence
  • Medical Errors / mortality*
  • Medical Errors / prevention & control
  • New Zealand / epidemiology
  • Patient Safety* / legislation & jurisprudence
  • Quality of Health Care