Mandatory responses to public health and safety recommendations issued by coroners: a content analysis

This study investigated the extent to which mandatory responses to coronial recommendations in one state of Australia (Victoria) provided a clear picture of action taken by organisations to protect public health and safety.

Analysis of organisations' responses to recommendations issued by coroners over the first three years of Victoria's newly introduced mandatory response regime was carried out.

Most responses were provided to the court within the legislated three-month timeframe and were signed by persons in senior or executive management. Analysis of 282 recommendation-response pairs, found that less than half (44%) provided explicit statements about whether action had or would be taken. In the remaining 56% of responses there was no explicit statement of action or intent. Ambiguity in the response was strongly associated with lack of implementation.

Our findings suggest that the founding objectives of Victoria's innovative mandatory response regime are being compromised by the opacity of many response letters. Implications for public health: Recommendations from the coroner can profoundly affect whether the community is exposed to unsafe practices, policies and products, but without such compliance, the potential for the coroner to make a meaningful contribution to protecting public and safety is substantially compromised.