A Hamilton couple whose baby died shortly after birth are calling for the coroner to have greater powers - including having recommendations enforced after an inquest.
The call is just one of a raft of ideas from Robert and Linda Barlow in their submission to Courts Minister Chester Borrows as part of a targeted review of the coronial system and the Coroners Act 2006.
The Barlows have spent three years trying to ensure that lessons are learned from the preventable death of their son Adam, and near-death of Linda, following a prolonged labour in 2009.
Earlier this year Coroner Gordon Matenga ruled that a "series of failures in care" by the Barlows' midwife, Jennifer Rowan, now known as Jennifer Campbell, contributed to the death of baby Adam.
But the inquest only took place at the insistence of Adam's father, Robert, who discovered his son, deemed to be stillborn, had shown signs of life after birth.
"The coronial system needs to be there to support the children that die and to support the midwifery profession as a whole by gaining as much knowledge and learning from these preventable deaths and thus strengthen the maternity system in the process."
Among his findings, Mr Matenga recommended that the guidelines for referring patients be amended, junior doctors consult a specialist when a woman with a complicated birth is admitted and that midwifery training be reviewed.
Mr Borrows said he appreciated the Barlows taking the time to send their submission for consideration.
"The Maternal Mortality Review Committee [MMRC] also exists to look at maternal and perinatal deaths," he said.
"The way the coroners interact with other agencies, such as the MMRC, is another matter being considered as part of the review."
The review was ordered when Mr Borrows discovered "room for further improvement" to the system after speaking with coroners and families.
"The coronial process impacts on families already grieving over the unexpected death of a family member," he said.
"I am keen to look at how we can improve the timeliness and efficiency of the coronial process to reduce the impact on those families."
Baby Adam's inquest was heard in February 2011, 16 months after his death, while his parents had to wait a further 12 months for the coroner's findings which were released in May this year.
"It has always been very important to us that learning and improvements can be made out of Adam's short life and that his short life has meaning," Mr Barlow said.
The review, led by the Justice Ministry, will include the views of professional groups including coroners, doctors, funeral directors and pathologists while public submissions have also been accepted by Mr Borrows.
Results of the review will be given to the minister in coming weeks who will then present the findings to Cabinet early next year.
Dr Wallace Bain released his findings into the death of Lower Hutt school teacher Rosemary Ives, who was shot by Hamilton man Andrew Mears as he was spotlighting for deer in the Kaimanawa Forest Park near Turangi.
Dr Bain called for harsher penalties for those who fail to properly identify targets and also recommended more education and messages to hunters of their obligations under the arms code, and general firearms safety and hunting training.
Hamilton coroner Gordon Matenga made five recommendations to the Corrections Department after the death of corrections officer Jason Clint Martin Palmer, who died following an incident at Springhill Prison in May 2010.
The recommendations included having a clear policy around the transfer of prisoners, formally adopting an alternative unlocking procedure for maximum security prisoners, reinforcing the training of staff around the reporting and recording of threats, and a "control and restraint stance" to be adopted by staff when unlocking a prisoner.
Coroner Peter Ryan backed calls for regulation of the refrigeration industry after his report into the death of Hamilton firefighter Derek Lovell, who died from injuries sustained in the Icepak coolstore explosion at Tamahere.
Mr Ryan recommended "consideration be given" to the licensing of gas suppliers and refrigeration engineers along with a licensing and inspectorate regime for those using hazardous substances that posed a "significant threat to life or property".
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