At the conclusion of an inquest the coroner may make comments and recommendations that are aimed at preventing deaths arising in similar circumstances. Indeed, in the course of a coronial investigation from the earliest stages there are opportunities to address matters of public health or safety. This is known as the coroner's death prevention role, a matter of extraordinary social utility and a cornerstone of the coronial process.
Please come and join us in Perth in November 2016 at the Asia Pacific Coroners Society's conference as the many pathways to prevention are explored.
Ros Fogliani
State Coroner for Western Australia