“…Concerns about the lack of monitoring and implementation of DVDR recommendations are similar to those that have been raised about the quality and effectiveness of recommendations made by other death review bodies, such as coroners (Bugeja, Ibrahim, et al, 2012;Bugeja, Woolford, et al, 2018;Grech, 2004;Moore & Henaghan, 2014;Sutherland, Bugeja, et al, 2014;Sutherland, Studdert, et al, 2016) and child death review teams (Wirtz et al, 2011). They also mirror concerns about the efficacy of public inquiry bodies more broadly (e.g., Buckley & O'Nolan, 2013;Mintrom et al, 2021;Stark, 2019;Stutz, 2008).…”