The chief coroner would like it to become mandatory for coroners' recommendations to be responded to.
Speaking on TVNZ's Q+A programme this morning, Judge Neil MacLean said people's lives were being lost because the recommendations were too often ignored.
"One step that I have cautiously pushed is to follow what the Brits do, what some of the Australian jurisdictions now do, and actually make it mandatory, compulsory, to respond to a coroner's recommendation.
"At the moment, our recommendations sort of can easily, so to speak, die in the ditch, because they go out there, they sit there, they're never actioned.''
Judge MacLean said cyber bullying, youth suicide and drug abuse were constant themes confronting coroners.
Last weekend 12-year-old Darius Logan Claxton died after inhaling butane with a group of friends in a Christchurch carpark.
This is despite coroners dealing with 28 butane deaths from 2007 to 2011, resulting in numerous recommendations.
"It's probably not fair to say nothing's happened. We do get responses to recommendations, but in a number of areas, I think coroners are feeling a sense of frustration that what they're saying seems not to be making any difference,'' Judge Maclean said.
Rotorua coroner Dr Wallace Bain told the Rotorua Daily Post if his recommendations after a Taupo jetski accident which resulted in the death of Genevieve Lewis had been followed, teenager Bishop Thompson, who died after a jetski accident on Lake Okareka, would be alive today.
Judge MacLean said most coroners would have experienced this.
"It is frustrating,'' he said.
It was pleasing the Government was trying to fast-track a Law Commission's report looking at tightening cyber-bullying legislation.
"The world that the parent grew up in is so different to what our young people are growing up in. I don't think we do understand. Most adults wouldn't even know about the dangers of butane, wouldn't even dream of sniffing petrol and that sort of thing. And they don't know and understand what's going on in cyber space.
"[Adults should] learn more, talk about it, get it out in the open. And that's where the coroner role and I think my role comes in, because I have a statutory responsibility to `educate the public'. Unusual thing for a judge to have to do. So that's all we can do - just keep talking about it. Be it suicide, be it solvent abuse, be it cyber bullying, whatever.''