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


  • OBJECTIVES: Exploring the characteristics of recommendations generated from medicolegal death investigations is an important step towards improving their contribution to injury prevention. This study aimed to: (1) quantify coroners' recommendations; and (2) examine the nature of these recommendations according to public health principles of injury causation and prevention. METHODS: Deaths where coroners' recommendations were and were not made in the State of Victoria, Australia during the period 1 July 2000 to 30 June 2005 were compared by sex, age group and underlying cause of death. The nature of recommendations made was examined retrospectively using a derived model based on principles of injury causation and prevention, comprising seven elements: (1) priority population; (2) risk/contributing factors; (3) countermeasure; (4) level of intervention; (5) strategy for implementation; (6) organisation; (7) time frame for implementation. RESULTS: Coroners' recommendations were relatively rare, made in only ∼6% of external-cause deaths. When coroners did make recommendations, they were statistically significantly more likely for persons aged 0-14 years and deaths resulting from transport crashes, complications of medical and surgical care, drowning and inanimate mechanical forces. Of the coroners' recommendations, ∼70% included at least four of the model's seven elements. The elements 'countermeasure' and 'level of intervention' were most commonly specified by coroners (∼95%) in their recommendations. CONCLUSIONS: This study shows that highly evolved medicolegal death investigation systems may not draw systematically from the scientific research evidence base to inform the formulation of coroners' public health and safety recommendations. To maximise its contribution to fatal injury prevention, the medicolegal death investigation may benefit from incorporation of a public health perspective.


  • Bugeja, L
  • Ibrahim, JE
  • Ozanne-Smith, J
  • Brodie, LR
  • McClure, RJ

publication date

  • 2012