Learning from Preventable Deaths: A prospective evaluation of reforms to Coroners' recommendation powers in Victoria

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Coroners in Australia investigate nearly 13,000 deaths each year and have a unique vantage point on health and safety risks. The public as a whole will benefit from information that helps translate those insights into system changes that work to prevent injuries and accidents from occurring. This project is designed to produce such information. It will also serve stakeholders at several other levels. By illuminating circumstances in which coroners recommendations produce positive change, project findings will help coroners shape and disseminate their prevention messages for maximum effect. Also, for states interested in modifying or boosting coroners' recommendation powers, our findings will help guide reforms.