Tasmania is rethinking its coronial system. Could it help prevent more deaths?
UNSW Sydney
Coroners can do more than investigate a death. They can help save lives.
Tasmania is reviewing its coronial laws giving the state an opportunity to make preventing future deaths, a less visible part of coronial work, more prominent.
The Tasmania Law Reform Institute (TLRI) is carrying out the review. UNSW Law & Justice Associate Professor Jennifer Schulz Moore has been invited by the TLRI to join the expert panel reviewing Tasmania’s Coroners Act 1995.
A/Prof. Schulz Moore has spent decades researching the role coroners can play in preventing future deaths. Her book, Coroners’ Recommendations and the Promise of Saved Lives, was the first data-driven investigation into the preventive power of coronial recommendations and the extent of their implementation. Her research shows coronial investigations can uncover information that doesn’t appear in medical records or other datasets.
Examined collectively, she says, these cases can reveal patterns, systemic problems and opportunities to prevent future deaths.
“Coroners’ investigations may reveal broader structural issues, policy failures, institutional flaws, public health and safety risks and patterns of risk that may disproportionately impact certain populations,” she says.
Examining the bigger picture
In Australia and New Zealand, coroners are judicial officers who investigate sudden and unexpected deaths. Unlike death investigators commonly portrayed on US television, they’re not medical specialists who carry out autopsies.
“Coroners are an inquisitorial jurisdiction. They investigate the death, gather the facts and try to get answers about what happened,” A/Prof. Schulz Moore says. “Coroners courts are unique because they are not part of the criminal or civil law systems; they’re not meant to be adversarial, unlike many other courts.”
But the information coroners gather can serve a purpose beyond establishing what happened.
“Coroners’ investigations can be very powerful for preventing deaths. We just need to lift our gazes beyond a single case, look at the big data sets carefully and notice the patterns.”
Research by A/Prof. Schulz Moore and Dr Paulo Henrique Silva Pelicioni from UNSW Medicine & Health shows how this can work in practice. Their research on falls among older Australians examined coronial cases to identify risks that might otherwise be missed. In one case, an aged care resident fell from their bed while staff were transferring them and later died. The coroner recommended appropriate equipment and training for staff carrying out transfers and routine care.
For A/Prof. Schulz Moore, cases like this show how investigating a death can identify risks for others.
When prevention is harder to see
But opportunities to make recommendations about how to prevent deaths may not always seem clear.
Research by A/Prof. Schulz Moore, UNSW Law & Justice Professor Chris Forster and Auckland University of Technology Professor Kate Diesfeld into suicide in the legal profession examines how coroners are investigating deaths by suicide but rarely make preventative recommendations because they view it as an individual mental health problem, which is not necessarily the case.
“What we argued in that research is that wellbeing in the legal profession is significantly impacted by structural failings and coroners can play an important role in preventing suicide by formulating recommendations,” she says.
A/Prof. Schulz Moore says the coroners’ cases highlighted that long working hours, court pressure, limited leave and professional isolation can form part of the circumstances surrounding these deaths. But coroners may feel that these factors are harder to translate into practical recommendations.
Transport accidents and drownings, for example, are perceived to present more tangible opportunities for prevention.
“Often, it’s because there’s a dangerous section of the highway that can be fixed, such as by erecting barriers to stop cars flying off the bridge and into the water,” A/Prof. Schulz Moore says.
“For some coroners, these deaths may seem more preventable because the interventions may feel more tangible and are something transport agencies can help implement.”
Preventative recommendations in decline
The type of death a coroner investigates is only part of the challenge, however.
In a study with former NSW Deputy State Coroner and UNSW Law & Justice Adjunct Professor Hugh Dillon, A/Prof. Schulz Moore examined whether the NSW coronial system was realising its preventative potential.
The researchers found that there was a decline in the number of coronial inquests and preventative recommendations between 2010 and 2024. According to A/Prof. Schulz Moore and Prof. Dillon, several factors may have contributed to the decline.
One is that coroners in NSW can only make preventative recommendations when an inquest is held, unlike coroners in other jurisdictions including Victoria and Aotearoa New Zealand where they have the power to make “in-chamber findings”.
“Our argument is not to discourage inquests, but don't restrict coroners to making recommendations only during inquests,” A/Prof. Schulz Moore says.
Another issue is the structure of the NSW coronial system. It sits within the Local Court, the largest magistrates’ court in Australia. Outside Sydney, regional magistrates handle coronial matters alongside their criminal and civil workloads.
A/Prof. Schulz Moore argues this structure makes it harder to develop the specialist expertise needed for death investigation and prevention.
“The coronial jurisdiction is special and unique; it’s a specialist jurisdiction so it needs to sit outside the criminal and civil court structures.”
The study also found coronial workloads increased, with the researchers suggesting that may have also contributed to a decline in the number of inquests and preventative recommendations.
Success stories
Despite these issues, there are many coronial prevention success stories. Lives have been saved by coroners making public health and safety recommendations about various types of deaths such as transport accidents, drownings, boating accidents, sudden deaths in infants and healthcare-related deaths.
A/Prof. Schulz Moore points out, for instance, how a coroner in Wellington, New Zealand recommended a median barrier be constructed along a major highway to reduce head-on collisions following the investigation of eight deaths that occurred within a year of each other, resulting in lives being saved.
She adds: “Coroners do important work that deserves more recognition and resourcing.”
For bereaved families who experience the coronial system, this life saving role is therapeutic and provides meaning to their loved ones’ lives. “Placing prevention at the heart of the coronial jurisdiction recognises families’ needs to be heard,” says A/Prof. Schulz Moore.
What can Tasmania do differently?
Tasmania’s review provides an opportunity to address some of these barriers. A/Prof. Schulz Moore points to Aotearoa/New Zealand and Victoria, both of which amended their coronial laws. Victoria’s Coroners Act is a “gold standard” because the state made prevention of future deaths core to its coronial system.
“They have a Coronial Prevention Unit where specialist support is available to coroners in Victoria,” she says. “This includes pathologists, epidemiologists, clinicians and researchers, who are there to help coroners write evidence-based and robust recommendations based on clinical and public health principles.”
With the final report of the Tasmanian review due in 2027, A/Prof. Schulz Moore sees an opportunity for the state to adopt similar approaches.
She wants the Tasmanian system to be a specialist jurisdiction which includes a prevention unit, allows coroners to make recommendations without an inquest, encourages consultation, promotes partnerships with researchers to monitor death prevention and requires public authorities to report how they respond to recommendations.
“I sincerely hope that Tasmania will seize this chance to be a local and global leader in fulfilling the coronial promise of saving lives,” she says.
Contact details:
For enquiries about this story and interview requests please contact Aimee Chanthadavong.
Tel: (02) 9348 1399
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