Jennifer Moore went through all the coronial recommendations from mid-2007 through mid-2012: 1644 of them. She makes a few reasonable recommendations about things the Coroner's Office could do to increase uptake of their recommendations: vaguely directed recommendations are unlikely to hit anybody's radar.
But she doesn't note one potentially important reason that at least some coronial recommendations don't lead to policy changes. The Coroners Act 2006 asks coroners to make recommendations of any changes that could reduce the likelihood of future similar deaths, but with no reference to any kind of cost constraint. So while the coroners will put out lots of really helpful and cost-effective recommendations, they'll also recommend things that seem extraordinarily unlikely to pass any kind of reasonable cost-benefit assessment. Mandatory high-visibility clothing (not just vests) for cyclists, mandatory helmets for riders of motorised skateboards, and mandatory fencing-off of farmhouses seem reasonable on a "if it saves only one life it's worth it" standard, but fortunately policy isn't based on that kind of standard. It's then hardly surprising that not all coronial recommendations turn into policy changes.
As I'd noted last year:
The problem seems to be in the Act. Pretty much anything that could reduce the chances of particular forms of death can be recommended; there's no consideration anywhere of costs. It's fine to say that that's Parliament's job. But Coronial recommendations carry some weight - people take them as being something more than "This is something that could save lives, but I have no clue whether it's worth it because I have zero training in policy assessment and cost-benefit analysis, so somebody else better figure out whether we'd be wasting a whole ton of resources in enacting it; moreover, the Act specifically asks me to just name any darned thing that might help even if it would cost a trillion dollars and save a life every fifty years."It would be interesting to go back through Moore's list to see whether some rough ballparking of cost-benefit ratios predict which coronial recommendations are taken up.