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PW 1875 Do we already have the answers to prevent deaths on our roads? in-depth analysis of coroners’ recommendations
  1. Marilyn Johnson1,2,
  2. Lyndal Bugeja1,
  3. Sjaan Koppel1
  1. 1Monash University, Australia
  2. 2Amy Gillett Foundation, Australia


In Australia, all fatal transport crashes are investigated by Coroners. Detailed information on a range of factors generated for these investigations is not available elsewhere, yet to date, this data and the coroners’ recommendations are not being maximised to inform road safety policy and practice to reduce trauma on the roads. Further, the insights from these investigations are not being shared internationally to benefit road safety efforts globally. This study is a retrospective, descriptive study examining coroners’ recommendations from 2000 to 2017. During that period, there were over 24 000 deaths on Australian roads resulting in more than 2000 coroners’ recommendations to analyse. The recommendations are being examined in terms of: target population; risk/contributing factor; countermeasure; intervention level; implementation strategy; organisation, and; implementation timeframe. Analysis is currently underway. To date, fatalities involving vulnerable road users and heavy vehicle have been examined. In the main, the recommendations related vehicle modification (rear vision camera, warning technology for older style truck cabins with visibility restrictions) and education in relation to driver behaviour and expectation of vulnerable road users as well as public education about safe behaviour around heavy vehicles and visibility restrictions. Analysis is continuing and will include all road user types. Findings from this study will provide a systematic analysis of the medico-legal death investigations conducted for road deaths in Australia. It is anticipated that findings will contribute to the United Nation’s Sustainable Goal 11.2 to provide access to safe, affordable, accessible and sustainable transport systems as insights will be transferrable internationally.

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