Application of a public health framework to examine the characteristics of coroners' recommendations for injury prevention

Bugeja, Lyndal; Ibrahim, Joseph E.; Ozanne‐Smith, Joan; Brodie, Lisa Ruth; McClure, Roderick John

doi:10.1136/injuryprev-2011-040146

Cited by 15 publications

(22 citation statements)

References 21 publications

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“…Consistent with an earlier study,16 most of the coroners’ recommendations described the ‘countermeasure’ element. The countermeasures most often mentioned were research and education strategies at the policy level.…”

Section: Discussionsupporting

confidence: 84%

“…We found that recommendations were made in less than 2% of external cause deaths of nursing home residents in Australia. Studies examining coroners’ recommendations following deaths from injury fatalities (6%, n=456) (Australia)16 and fatal heavy vehicle crashes (6%, n=21) (Australia)17 are consistent with this finding.…”

Section: Discussionsupporting

confidence: 54%

“…The nature of the recommendation rather than the outcomes was examined 16. Future evaluations should consider whether a recommendation was implemented and if so the impact on morbidity and mortality.…”

Section: Discussionmentioning

confidence: 99%

“…The method for quantifying and describing the nature of coroners’ recommendations consists of seven elements (please see online supplementary box appendix 2) and was developed from internationally accepted and applied public health models of mortality causation and prevention and consultation with relevant experts (two senior epidemiologists and a coroner) 16. Two researchers (LB and MW) independently reviewed and classified the recommendations according to the seven elements, and a third researcher (JEI) adjudicated to resolve any discrepancy.…”

Section: Methodsmentioning

confidence: 99%

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Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study

et al. 2017

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Section: Discussionsupporting

confidence: 84%

Section: Discussionsupporting

confidence: 54%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study

et al. 2017

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“…Some commentators have questioned the appropriateness of arming coroners with recommendation powers [3-5]. Criticism has also been levelled at the practicality and evidentiary basis of some recommendations [6-9]. However, the most prevalent concern, voiced in a succession of public inquiries [10-12], is that coroners’ recommendations are ineffective because the organisations and industries to which they are directed ignore them.…”

Section: Introductionmentioning

confidence: 99%

What happens to coroners’ recommendations for improving public health and safety? Organisational responses under a mandatory response regime in Victoria, Australia

et al. 2014

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BackgroundSeveral countries of the British Commonwealth, including Australia and the United Kingdom, vest in coroners the power to issue recommendations for protecting public health and safety. Little is known about whether and how organisations that receive recommendations act on them. Concerns that recommendations are frequently ignored prompted the government of Victoria, Australia, to introduce a requirement in 2008 compelling organisations that receive recommendations to provide a written statement of action.MethodsWe conducted a prospective study of organisations that received recommendations from Victorian coroners over a 33-month period. Using an online survey, we asked representatives of "recipient organisations" what action (if any) their organisations took, and what factors influenced their decision. We also probed views of the quality of the recommendations and the mandatory response regime in general. Responses were analysed at the recommendation- and recipient organisation-level by calculating counts and proportions and using chi-square analyses to test for sub-group differences.ResultsNinety of 153 recipient organisations surveyed responded (59% response rate); they received 164 recommendations (mean = 1.9; range, 1–7) from 74 cases. A total of 37% (60/164) of the recommendations were accepted and implemented, 27% (45/164) were rejected, and for 36% (59/164) the recommended action was "supplanted" (i.e., action had already been taken). In nearly half of rejected recommendations (18/45), recipient organisations indicated implementation was not logistically viable. In half of supplanted recommendations, an internal investigation had prompted the action. Three quarters (67/90) of recipient organisations believed the introduction of a mandatory response regime was a good idea, but fewer regarded the recommendations they received as appropriate (52/90) or likely to be effective in preventing death and injury (45/90).ConclusionsOnly a third of coroners’ recommendations were implemented by the organisations to which they were directed. In drawing policy lessons, it is important to separate recommendations that were rejected from those in which action had already been taken. Rejected recommendations raise questions about the quality of the recommendations, the reasonableness of the organisation’s response, or both. Supplanted recommendations focus attention on the adequacy of consultation between coroners and affected organisations and the length of time it takes for recommendations to be issued.

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Preventing river drowning deaths: Lessons from coronial recommendations

Peden

Franklin

Leggat

2018

Health Prom J of Aust

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Coronial recommendations associated with river drowning in Australia are reasonably rare. Recommendations provide opportunities for organisations to enact change, however, they could be strengthened with a specified time period and higher order control strategies recommended. SO WHAT?: SMART coronial recommendations may be more successful in achieving the behavioural, social and societal change required to prevent future river drownings. The recommendations examined in this study can be used as a benchmark for what could be considered appropriate safety actions.

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Application of a public health framework to examine the characteristics of coroners' recommendations for injury prevention

Cited by 15 publications

References 21 publications

Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study

Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study

What happens to coroners’ recommendations for improving public health and safety? Organisational responses under a mandatory response regime in Victoria, Australia

Preventing river drowning deaths: Lessons from coronial recommendations

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