Coroners are frustrated that their recommendations are being left to "die in a ditch" rather than being actioned - and say mandatory responding to their suggestions could save lives.

But the Government says the vast number of recommendations made each year meant such a process would be too complicated and has no plans to implement the change.

Chief Coroner Judge Neil MacLean said yesterday that many coroners around the country were frustrated that recommendations they made did not seem to be making any difference.

He was pushing for changes that would make it compulsory for agencies and organisations to respond to coroners' recommendations.


Through inquest hearings coroners identify the causes and circumstances of sudden and unexplained deaths, or deaths in special circumstances. They make recommendations that, if drawn to public attention, might reduce the chances of occurrence of future deaths in similar circumstances.

But those recommendations do not have to be responded to, or adhered to by the organisation or agency they are targeted at.

"In a perfect world, we'd like to think that we'd made a serious recommendation and something gets done about it," Judge MacLean told TVNZ's Q+A programme.

"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 ... and then have a system of monitoring it.

"Because at the moment, our recommendations can easily, so to speak, die in the ditch, because they go out there, they sit there, they're never actioned."

Associate Justice Minister Chester Borrows said last night that there was no plan to make responding to recommendations mandatory.

However, a review of the Coroner's Act would include looking at how agencies responded.

Mr Borrows did not think mandatory responding was necessary.


"There is the ability for that to get quite complicated."

He said if coroners made recommendations that clashed, or made too many requests on organisations, the outcome would be confusing.

"I accept coroners might be frustrated. But Government agencies and others do take recommendations seriously and consider them. There is a broad range of recommendations and they are fairly wide-reaching."

Judge MacLean accepted not all recommendations were ignored.

"It's probably not fair to say nothing's happened. We do get responses to recommendations ... But we've got to live in the real world. There's so many demands on Government and people and society to try and rectify lots of wrongs."

One area where coroners felt significant frustration was in the cases of deaths related to butane inhalation - or huffing.

Last weekend 12-year-old Christchurch boy Darius Claxton died after huffing butane with friends.

He is one of 28 young people who have died in similar circumstances between 2007 and 2011.

A recommendation was made in March after a similar huffing death.

In 2010 Nikora Mikaere Harepaati Birch, 16, was found dead on the banks of a stream in Wainuiomata. Earlier that day he had bought a can of butane from a dairy. An empty can was found beside his body.

Coroner Garry Evans recommended the Government take a fresh look at ways to control the supply of substances such as butane and the policing of volatile substance abuse.

Judge MacLean said that recommendation had been referred to the Child and Youth Mortality Review Committee which was proposing to "do some work".

He said butane abuse was "quite serious" and hoped more notice would be taken of the recommendations.

* The chief coroner has said many coroners around the country are frustrated that recommendations they are making do not seem to make any difference.
* He is pushing for changes that would make it compulsory for agencies and organisations to respond to coroners' recommendations.
* Last night the Associate Justice Minister said there was no plan to make responding to recommendations mandatory.