New study identifies serious failings in the coronial system

The University of Otago study was funded by the Law Foundation, and looked at more than 600 coronial inquiries that took place between 2007 and 2012. It's key finding was that the preventive and patient safety potential of coroners' recommendations is not being maximised due to serious systemic issues and under-resourcing. Jennifer Moore is the Acting Director of the Otago University Legal Issues Centre.