Mandatory responses to public health and safety recommendations issued by coroners: a content analysis.
OBJECTIVE
This study investigated the extent to which mandatory responses to coronial recommendations in one state of Australia (Victoria) provided a clear picture of action taken by organisations to protect public health and safety.


METHODS
Analysis of organisations' responses to recommendations issued by coroners over the first three years of Victoria's newly introduced mandatory response regime was carried out.


RESULTS
Most responses were provided to the court within the legislated three-month timeframe and were signed by persons in senior or executive management. Analysis of 282 recommendation-response pairs, found that less than half (44%) provided explicit statements about whether action had or would be taken. In the remaining 56% of responses there was no explicit statement of action or intent. Ambiguity in the response was strongly associated with lack of implementation.


CONCLUSIONS
Our findings suggest that the founding objectives of Victoria's innovative mandatory response regime are being compromised by the opacity of many response letters. Implications for public health: Recommendations from the coroner can profoundly affect whether the community is exposed to unsafe practices, policies and products, but without such compliance, the potential for the coroner to make a meaningful contribution to protecting public and safety is substantially compromised.
Melbourne School of Population and Global Health, University of Melbourne, Victoria. georgina.sutherland@unimelb.edu.au.
Georgina
G
Sutherland
Melbourne School of Population and Global Health, University of Melbourne, Victoria.
Celia
C
Kemp
Stanford University School of Medicine & Stanford Law School, USA.
David M
DM
Studdert
D002423:Cause of Death; D003334:Coroners and Medical Examiners / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D011634:Public Health; D012449:Safety; D014739:Victoria
content analysis; coroner; prevention; recommendations