Coronial recommendations and the prevention of indigenous death.

This report details on a national study of the law and practice relating to coronial recommendations undertaken by the authors. The study collected and analysed data on the implementation of coronial recommendations, and carried out a number of case studies which examined the factors impacting upon whether or not coronial recommendations were implemented. An initial aim of the research was to compare the implementation of coronial recommendations arising from Indigenous deaths with the implementation of those arising from non-Indigenous deaths. However, such a comparative study was abandoned when it became apparent that the recording of Indigenous status in relation to inquests is not wholly reliable. It was realised that any meaningful exploration of coronial recommendations in relation to Indigenous deaths needed to be preceded by a national study of coronial recommendation implementation practices more generally. Unfortunately, no such study existed. This research attempts to provide such a study.