Abstract
Coroners can make recommendations about the cases they investigate to reduce the chances of further deaths in similar circumstances. Coroners all have a background in law and are not required to have any other qualifications to become a coroner. Previous research in Aotearoa/New Zealand and overseas has shown there are complexities around coroners’ preventive role, to do with the scope of the coronial preventive role, coroners’ expertise in preventing future death and matters relating to how recommendations are received and acted upon by recipient entities.
Given the lack of formal training coroners have in prevention, the aim of this research was to investigate how to improve the preventive elements of coroners’ recommendations, including the evaluation of an intervention that consisted of an education programme and support.
An exploratory sequential mixed methods research design was used. Interviews were conducted early in the research to explore coroners’ perceptions about how their recommendations could be enhanced, and to provide context and understanding about coroners’ workflow, day to day activities and other factors that could impact their recommendation making role. A literature review was undertaken to inform the development of a framework, which was used to quantify the characteristics of recommendations that coroners make. The literature was also reviewed to explore the question of whether health promotion and death prevention can be considered to be the same entity. Sudden Unexpected Death in Infancy (SUDI) was chosen as an example to review, to determine how our current approaches to death prevention align with our knowledge of prevention, particularly with regard to reducing inequities. Educational theory relating to teaching adults was used to develop the intervention, which was an education programme, delivered to coroners in three sessions over the course of 15 months. All deaths in children and young people aged 28 days to 24 years, during the time period 2016 to mid 2023 were examined. Demographic analysis of cases was undertaken to describe the population of cases that enter the coronial jurisdiction in this age group. Coronial cases were searched for recommendations. The framework was applied to recommendations made before and after the intervention was delivered, as part of the evaluation of effectiveness. Coroners provided feedback after each education session which was used to improve subsequent sessions and to inform the evaluation of the intervention. A second round of interviews was undertaken to also inform the evaluation.
There were 3,901 children and young people who died over the study time period, 2,873 (74%) of which entered the coronial system. A total of 125 unique recommendations were made. The framework analysis provided useful information about the characteristics of coronial recommendations, and the education programme was found to be beneficial. Coroners reported that the education programme had changed their approach to making recommendations, although pre- and post-intervention testing did not show any tangible increase in knowledge over the study period.
Despite being beneficial, an education programme on its own is insufficient to fully utilise the preventive role coroners have. There are other impediments to coroners fully realising the potential of this role, and recommendations are made relating to ongoing education and support, tools to assist coroners and legislative changes to support their work.