Chief Coroner 2019-20 Annual Report [pdf, 2 MB]
...increase the timeliness of coroners’ investigations. I hope you find this Annual Report of interest. It contains a sample of the kinds of recommendations / comments coroners made during the year. This is an important aspect of a coroner’s role, designed to prevent similar deaths occurring in the future. Further examples can be found in our recommendation recaps which are published on the Ministry of Justice website. https://coronialservices.justice.govt.nz/findi ngs-and- recom...