Grieving families are devastated that the roads that killed their loved ones are not being fixed because of repeated bureaucratic bungles.
Coroners' recommendations are being lost or ignored by the public bodies charged with making New Zealand's streets and highways safe. A Herald on Sunday investigation into five years of road deaths reveals that coroners' recommendations for at least three were lost and never acted on and those from another five deaths were ruled out by the NZ Transport Agency or local authorities as unnecessary because the coroners had got it wrong. In four more cases, authorities accepted the advice, but decided that they didn't have enough funds to do anything about it, at least for the time being.
In the cases of 44 more deaths, authorities have not explained what - if anything - they did to fix the dangerous roads. Recommendations stemming from only 16 of the 71 reports were carried out.
Cushla Tangaere lost her brother Edward on Christmas Eve, 2009. He and his friend Edwin Ward died when their car spun out on a corner, in a remote area of the East Cape.
The coroner recommended NZTA's predecessor, Transit New Zealand, put up speed and corner advisory signs - but to Cushla's dismay, there are still no warning signs.
"Nothing has been done," she said. "A woman who lived on that corner had been lobbying for changes and had said that corner was an accident waiting to happen. I know alcohol was a factor in the crash but if something good can come out of this and a sign can warn others then it should be put up."
NZTA spokesman Andrew Knackstedt said the agency had no record of having received a recommendation made following the death of Ward and Tangaere.
In the past two years, coroners have recommended six road safety improvements to the NZTA - but only one has been implemented. Apart from the East Cape instruction, one recommendation was still being considered, two were investigated but considered unnecessary and the last one was earmarked as high priority, but was subject to funding.
The two recommendations that were disregarded were a review of the licensing eye test, after a man with impaired sight died after failing to give way to a vehicle he did not see, and a review of the pink-sticker regime which gives NZTA enforcement officers the right to impound defective vehicles.
Farmer Paul Robinson, who would have turned 40 yesterday, died when a bridge collapsed beneath the loader he was driving. His wife and mother do not have the comfort of knowing that safe speed and loading limits have been set in place for bridges on private land, as the coroner recommended.
The Department of Internal Affairs said it had no record of receiving the recommendation, after Robinson's fatal plunge into Taranaki's Mohakatino River in 2008. The coroner ruled that an undiagnosed brain tumour that may have caused him to veer on to a weaker part of the bridge, which collapsed.
Department spokeswoman Jo Watt said they didn't have the relevant powers to conduct the research anyway.
Part of the coroner's role is to make suggestions on how tragedies can be prevented, but there is no legal requirement for the recommendations to be carried out, or even for authorities to respond to the advice.
In Hawke's Bay, widow Mariee Carr is disappointed the Hastings District Council has not followed a recommendation to install barriers on the road where her husband Mervyn died more than a year ago.
Mervyn, 72, died of multiple injuries when the car he was driving missed a hairpin bend and rolled about 300 metres down the bank on Te Mata Peak Road on October 16, 2010.
The coroner investigating her husband's death said roadside barriers were needed to prevent similar deaths because of the restricted visibility.
"If they had put barriers up, my husband would still be with me today," she said. "If the council don't listen to the coroner I can foresee more trouble ahead for another family."
In the year following Mervyn's death, a 60-year-old Hawke's Bay woman was lucky to survive a 70m plunge after her car veered off the same road, and a group of four teenagers who plunged 150m off the road were similarly fortunate.
Council spokesman Ross Holden said Te Mata Peak Rd was included in the council's long-term plan.
"An investigation and implementation project ... will look at the whole of Te Mata Peak Rd including the hairpin bend and determine what improvements are required," he said.
Further south, the Timaru District Council has not followed a recommendation to drop the speed limit or put up a guard rail on a bridge where a motorcyclist died in 2008. The council's land transport manager Andrew Dixon said the recommendations were noted and investigated but the district had many more narrow bridges.
And the Invercargill City Council has not followed a coroner's recommendation to upgrade the road where three young men lost their lives 2 years ago.
Alcohol, speed and the car's suspension were factors in the crash, but the coroner also asked the council to repair the road surface in Leven St.
Cameron McIntosh, the council's director of works, said the road surface condition was assessed and was not sufficiently degraded to warrant intervention at that time, but it is scheduled to be resurfaced in the 2012/2013 financial year subject to funding availability.
The NZTA's Andrew Knackstedt said coronial inquests played an important role in the ongoing effort to reduce deaths and serious injuries on our roads.
"The NZTA is concerned by every fatal crash on New Zealand roads, and we look carefully at the causes of every one, including reviewing coroners' reports and recommendations. In some cases recommendations are adopted, in other cases the issues raised in recommendations may be addressed in different ways," he said.