Editorial: Heed the warnings

Wellington coroner Ian Smith was clearly frustrated this week in the wake of another death on a quad bike.

"What's the point?" he asked, in coroners hearing evidence, making recommendations and then ... nothing.

His frustration is understandable.

There is a longstanding and significant flaw in the coronial process in New Zealand.

Hearings do have a valid purpose. They bring evidence together, the coroner makes a ruling on cause of death, and the family has some point of closure.

But another benefit, that of making changes so not to repeat certain incidents, is lost. Recommendations coroners make carry little weight, and if it wasn't for the media highlighting them, might get no airing at all.

A good example locally has been the case of Ian Joyce, who died in his caravan as a result of carbon monoxide poisoning. Coroner Richard McElrea said the case highlighted the need for proper ventilation and carbon monoxide sensors, and recommended warnings be placed on an Energy Safety website.

In this case the family was proactive and willing to push the same safety message, and media coverage saw many caravan owners install the devices.

Yet to our knowledge no politician nor government department has taken up the case, no laws have been changed.

Indeed, there is no requirement on anyone to do anything.

No wonder coroners are frustrated.

Eight months ago chief coroner Neil McLean said it should be mandatory for agencies to respond to coroners' recommendations.

Most people would be surprised that this wasn't already the case.

And that there isn't a national database that groups together similar findings.

Mr McLean points to huffing as an example where there is a bigger picture that isn't being adequately addressed, despite 63 people dying in the last 12 years from inhaling substances.

Quad bikes is another, with an estimated 120 people dying in accidents in the last 10 years.

These aren't easy problems to fix, but there is little chance of improvement if no-one follows them up.

In Australia and the United Kingdom it is mandatory that agencies consider coroners' findings, and coronial services here are examining if that would work here.

That would seem a no-brainer.

It does not make sense that so much good and painfully-learnt information is available, only for it to disappear into a great black hole.

The Timaru Herald