When Wairarapa 21-year-old Jody Santos died after the quad bike he was riding rolled, he joined a long line. About five people die and 850 others are injured riding quad bikes on farms each year.

At the inquest into Jody's death, coroner Ian Smith, exasperated by a steady flow of similar cases, made several recommendations, including making rollbars and seatbelts mandatory on quad bikes. He was ignored, although the Department of Labour launched a large education campaign.

Yet last year four people died in quad-bike accidents.

Jody's legal guardian, Ryan Soriano, is pleading for officials to act on Smith's recommendations.


However, New Zealand does not require government departments and local council to follow recommendations, or even respond to them.

In the Australian state of Victoria, they track what actions are taken to save lives.

"I think it's probably the way to go if we're to serve a useful purpose," said Chief Coroner Neil MacLean, "but it does raise some huge resourcing issues."

About 250 deaths come before New Zealand's 15 coroners each year, but an inquest can be launched only after every other investigation, such as a police inquiry, is finished. It can sometimes take years to reach the inquest stage.

Courts Minister Chester Borrows said a number of recommendations had received public attention and resulted in changes to policies or infrastructure.

But he admitted the interaction between coroners and other agencies could be improved.

A Herald on Sunday investigation into five years of road deaths found 34 coronial recommendations were fully implemented, 13 were partly implemented and 14 disregarded. Eight more recommendations got lost in the system.

Coronial Services of New Zealand has engaged two Otago University academics in a two-year project to evaluate the Coroners Act and the effectiveness of recommendations.

Parents' relief over inquest

Robert and Linda Barlow were not convinced their son, Adam, was stillborn in 2009 so took their medical notes to the coroner.

An inquest was held into Adam's death and this week Coroner Gordon Matenga said the midwife's inexperience was partly to blame.

Robert Barlow said it was hard to listen to details of how his son died, but the 10-day inquiry was "thorough and rigorous".

"To have the Coroner listen to our concerns, it's hard to put it into words how we felt, but you can imagine it was a huge relief."