Every coronial inquiry begins with a tragedy, but one of the most important outcomes can be the recommendations made to help prevent similar deaths from happening again.
The latest Recommendations Recap published by the Office of the Chief Coroner highlights the breadth of those efforts, bringing together 102 coronial findings containing recommendations and comments issued between 1 October and 31 December 2025. The report demonstrates how coroners are not only tasked with determining how someone died, but also with identifying opportunities to improve public safety across Aotearoa.
Under the Coroners Act 2006, coroners investigate sudden, violent and unexpected deaths, deaths where the cause is unknown, and deaths that occur in specific circumstances set out in legislation. During those inquiries, coroners may make recommendations or comments aimed at reducing the likelihood of similar deaths occurring in the future.
Those recommendations are compiled into a public register maintained by the Chief Coroner, with summaries published where they are not restricted by law or court order. The quarterly Recommendations Recap provides a snapshot of the issues repeatedly emerging across the country and the changes coroners believe could save lives.
A Strong Emphasis on Prevention
The 102 findings reveal a consistent focus on strengthening systems rather than assigning blame. Many recommendations call for government agencies, health providers, regulators, employers and community organisations to review policies, improve procedures and strengthen safeguards where risks have been identified.
Across the report, coroners repeatedly identify opportunities to improve communication, increase public awareness, strengthen training, review operational practices and ensure lessons learned from previous incidents are acted upon.
The recommendations recognise that preventing future deaths often requires coordinated action between multiple organisations rather than changes by a single agency.
Improving Healthcare Systems
Healthcare remains one of the largest areas attracting recommendations.
Many findings encourage improvements to patient assessment, clinical decision-making, discharge planning, follow-up care and communication between healthcare providers. Better information sharing and more consistent clinical processes are identified as important measures to reduce avoidable harm.
Recommendations also highlight the importance of recognising deteriorating health conditions earlier and ensuring patients receive appropriate care pathways.
Mental Health and Community Support
Mental health continues to feature prominently throughout the report.
Recommendations encourage stronger coordination between mental health services, improved crisis response systems, enhanced continuity of care and greater support for individuals identified as being at heightened risk.
Coroners also identify opportunities to improve engagement with whānau and ensure support services work more effectively together.
Safer Roads and Transport Networks
Road safety remains a recurring concern, with recommendations spanning driver behaviour, infrastructure, heavy vehicles, motorcycles, pedestrian safety and rail environments.
Several findings encourage reviews of road design, signage, speed management, traffic controls and public education initiatives aimed at reducing fatal crashes.
The recommendations reinforce that preventing transport-related deaths requires both safer infrastructure and safer behaviour.
Water Safety Continues to Demand Attention
New Zealand’s rivers, lakes and coastlines continue to be the subject of numerous coronial recommendations.
The report calls for improved hazard identification, better warning signage, stronger public education and enhanced emergency preparedness in locations where water-related fatalities continue to occur.
Coroners also encourage organisations responsible for recreational areas to regularly review safety measures and public information.
Workplace and Public Safety
Workplace incidents remain another significant area of focus.
Recommendations encourage employers and regulators to strengthen health and safety systems, improve staff training, ensure appropriate supervision and regularly review operational procedures.
Other findings relate to public spaces and recreational activities, where coroners identify opportunities to improve safety standards, maintenance and risk management.
Protecting Vulnerable People
Many recommendations focus on protecting vulnerable members of the community, including older people, children, people living with disabilities and those experiencing complex health or social challenges.
Coroners frequently recommend earlier intervention, improved communication between agencies and more coordinated approaches to supporting people whose circumstances place them at greater risk.
The report reinforces that effective prevention often depends on recognising vulnerability before tragedy occurs.
Transparency Through a Public Register
The Chief Coroner is required by law to maintain a public register of coronial recommendations and comments. While not every finding can be published because of legal restrictions, the Recommendations Recap provides an important level of transparency by making publicly available the lessons arising from coronial investigations.
Although coroners cannot require organisations to implement their recommendations, many agencies use the findings to review policies, update procedures and improve public safety measures.
Learning From Every Loss
The latest Recommendations Recap serves as a reminder that every coronial recommendation represents an opportunity to learn from tragedy.
Collectively, the 102 findings issued during the final quarter of 2025 highlight recurring risks across health, transport, workplaces, public spaces and community services, while reinforcing the important role coroners play in driving improvements that can help prevent future deaths.
Rather than ending with a determination of how someone died, many coronial inquiries leave behind practical recommendations intended to make Aotearoa a safer place for everyone.
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