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Application of a public health framework to examine the characteristics of coroners' recommendations for injury prevention
  1. Lyndal Bugeja1,
  2. Joseph Elias Ibrahim2,
  3. Joan Ozanne-Smith3,
  4. Lisa Ruth Brodie1,
  5. Roderick J McClure1
  1. 1Monash Injury Research Institute, Monash University, Victoria, Australia
  2. 2Department of Forensic Medicine, Monash University, Victoria, Australia
  3. 3Prevention Research Unit, Department of Forensic Medicine, Monash University, Victoria, Australia
  1. Correspondence to Dr Lyndal Bugeja, Monash Injury Research Centre, Building 70 Monash University Clayton, Victoria 3800, Australia; lyndal.bugeja{at}


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.

  • Death investigation
  • coroner
  • medical examiner
  • recommendations
  • policy
  • drowning
  • implementation/translation
  • violence
  • mortality
  • legislation
  • asphyxia
  • animal
  • bites
  • government
  • database
  • head injury
  • international
  • developing nations
  • methods
  • evaluation
  • product
  • epidemiologic
  • surveillance
  • health services
  • child
  • public health
  • occupational
  • epidemiology

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  • Funding An Australian Postgraduate Award supported the first author's PhD candidature, and funding was provided by the Monash University Accident Research Centre Doctoral Student Research Fund to support research assistance and to enable coding of ICD-10 cause of death.

  • Competing interests LB and LRB are currently employed in the Coroners Prevention Unit at the Coroners Court of Victoria. However, at the time the research was conducted, they were employed by Monash University. JEI, JO-S and RJMc have no competing interests, financial or otherwise.

  • Ethics approval Ethics approval was provided by Monash University Human Research Ethics Committee and Department of Justice Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.