The phenomenon of cot death was the most difficult death for the former chief coroner to watch over, and babies could have been saved if the recommendations coroners made were responded to.

Judge Neil MacLean has been the Chief Coroner of New Zealand since 2007. After eight years, his time in the position is up and he is returning to the District Court in a role as an ACC appeals judge.

Judge MacLean said after his time as Chief Coroner he wanted to see mandatory responses to recommendations made by a coroner.

He said when he was a young coroner he dealt with a spate of cot deaths in Christchurch, now known as Sudden Unexplained Death of an Infant, and that those were some of the hardest cases he's ever seen.


"It made one very conscious of how fragile a baby's life is, that kind of helpless feeling you have when you realise that sometimes you just can't control what's happening," he said.

He expressed regret that recommendations coroner's had made about cot death weren't responded to.

"There was a consistent message coming through from coroners over the years emphasising the danger of co-sleeping, particularly the danger of co-sleeping when the adult was under the influence of drugs or alcohol or simply sheer exhaustion."

He said it was only after a joint investigation with a university professor that the message began to get out that in some cases there was an explanation for the death and it was an adult smothering the baby.

"If that message had been heeded across the board earlier there would've been a lot of babies that did not die."

He said he wanted to see coroner's recommendations around quad-bikes and their use responded to, and said people will keep dying on the farm equipment if changes aren't made.

Suicide had been a topic that Judge MacLean had spoken about throughout his career.

He said he had seen the attitude towards suicide change from "taboo" to a topic the public and media were "intensely interested about".


"Simply because we have this staggering phenomenon of suicide... bigger than the road toll now.

"I think the enormity of that is becoming more apparent and increasingly I find a huge appetite amongst public and professionals to say 'what's going on'."

He said he was "none the wiser" as to why New Zealand's suicide rate was so high, and said there was no simple answer to any suicide.

"We'll never understand it, really."

The only time in his career where he has been kept awake at night by a case was during his management of the body identification process for the victims of the Christchurch Earthquake.

"You were living in this artificial bubble of calmness out there in Burnham [Military Camp] while they got on with their task, conscious of the chaos and devastation just down the road."

Judge MacLean said after seeing the outcome of young people's low tolerance to alcohol he thought the drinking age should be raised.

His wife and son were at his farewell address to media, and his wife audibly laughed when Judge MacLean was asked whether his new role would mean a slower pace.

Deborah Marshall has been appointed the new Chief Coroner.