Introduction A purported strength of the medico legal death investigation system (coroner or medical examiner) is the provision for formal recommendations to be made about the prevention of fatal injury. Recent changes in the United Kingdom and Australia are requiring organisations to respond to coroners recommendations.

Aim To describe the nature of coroners recommendations for injury fatalities in Victoria, Australia using a novel model.

Methods Injury fatalities investigated by the coroner were extracted for the State of Victoria from the Australian National Coroners Information System (1 July 2000 – 30 June 2005). Unique coroners recommendations were examined by incident using a derived model comprising seven elements important for injury prevention: (1) population at risk; (2) risk/contributing factors; (3) countermeasure; (4) level of intervention; (5) strategy for implementation; (6) organisation; and (7) timeframe for implementation.

Results Of the 7655 injury deaths (from 7394 incidents) investigated by the coroner, only 456 (6%) deaths (407 incidents) had recommendations, 338 of which were unique. Overall, most unique coroners recommendations described the elements (5) strategy for implementation (n=320, 94.7%) and (3) countermeasure (n=318, 94.1%). Few recommendations described elements (1) population at risk (n=185, 54.7%) or (2) risk/contributing factors (n=175, 51.8%).

Recommendations About transport-related deaths had the most comprehensive coverage of the seven elements.

Discussion and conclusion Coroners make few recommendations for the prevention of injury fatalities. There are significant gaps in their formulation with incomplete adherence to the principles of injury prevention. This information is an essential step to improving the formulation of coroners recommendations and optimising their capacity for prevention.