The chief coroner, Judge Neil MacLean, has expressed the frustration of all coroners when their recommendations are not taken up by governments and their agencies. He would like to see the law make it mandatory upon authorities to respond in some way and for their response to be monitored.

The frustration can be well understood. Coroners hold inquiries into causes of death. They hear harrowing accounts of personal misfortune and avoidable tragedy. When they deliver their findings they are often in front of the bereaved. When their verdicts are reported there may be a temptation to discount their warnings and recommendations as consolation for those in grief rather than practical suggestions for public policy.

But if consolation was the coroners' only intention, they could be a great deal more outspoken than they are. Coroners generally express themselves with great care and restraint. Consequently, when they are moved to criticise something that governments can fix or improve, they are taken seriously.

They might not see much happen as a result but Judge MacLean and his fellow coroners should not imagine they are ignored. If the public impact of their recommendations seldom lasts more than a day or so, the same is true of a great deal of advice to governments, often from inquiries that take much longer and investigate more comprehensively than a coroner's inquest.


Many a commission, having put months or years of work into research and consulted widely, must wonder what is happening to its report a week after its release. The answer will depend on whether the Government, when it set up the inquiry, was genuinely anxious to act on the problem or looking for a way to sideline it.

Politics is the art of the possible. The gap between the ideal recommendations and practical political action will depend on the state of public opinion, the courage of politicians, the capabilities of the public service, the finance available and other matters competing for attention.

Coroners' recommendations are concerned with matters of life and death, which must give them high priority for consideration within the public service.

Judge MacLean's call for mandatory consideration, and monitoring of it, merely seeks to formalise what should happen anyway. But he should perhaps be careful what he wishes for.

Would coroners speak as freely if they knew that any suggestion they were moved to make in the emotions of an inquest would set officials to work somewhere in the public service? Would the time and expense involved in investigating the practicalities of their suggestion and the monitoring and reporting of its official consideration inhibit them? And would a mandatory response be any better? Departments are adept at satisfying statutory requirements without much actually happening.

As responsible public officers, coroners could easily be made more cautious by the power Judge MacLean proposes for them. In that event, the country would be less well served than it is now when they raise a subject of concern.

They should not imagine they are ignored. Their findings and warnings go on the record to be constantly available and capable of haunting those in power. It is not theoretical or conjectural advice open to argument, it is supported by an avoidable death.

In the past week alone, coroners have called for action against techniques of cyber-bullying, drawn attention to the danger of stoves toppling if an infant crawls on to the door, and found deficiencies in a midwife's training. Those responsible for these sorts of dangers surely do not need the law to tell them they ignore a coroner at their peril.