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. METHOD: 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.