Lay summary
Sudden and unexpected deaths are referred to the coroner. A coroner will establish that a person has died, the person’s identity, the causes of death, and the circumstances of death. Coroners are also able to make recommendations that may, in the coroner's opinion, reduce the chances of other deaths occurring in similar circumstances if brought to public attention. Māori are disproportionately represented within the coronial system and, therefore, are disproportionately impacted by its functioning. In the Aotearoa New Zealand context, there is no requirement for coroners’ recommendations to be implemented. Furthermore, there is not a requirement for organisations to respond to any recommendation that is directed to them. This research aims to quantify the number of recommendations for which an organisational response is published, and to analyse characteristics of any such responses in order to contribute to the discourse around a legislative requirement for mandatory organisational responses.