Objective: This paper quantifies and describes the nature of coroners' recommendations and comments on fatal heavy vehicle crashes in Victoria, Australia.
Methods: A retrospective, descriptive study was performed using coroners' findings. Fatal heavy vehicle crashes between January 2001 and December 2007 were identified through coronial databases. Individual findings were examined by incident type. Identified recommendations or preventative comments were reviewed and compared with national heavy vehicle safety objectives.
Results: Of 330 fatal crashes, which resulted in 376 deaths, recommendations were made in 21 incidents (6%). From these 21 incidents, 45 separate recommendations or comments were made by coroners. Ten (22%) called for specific remedial action, predominantly targeting road environment changes; the remainder had a broader application for prevention. Of the 21 incidents from which these recommendations arose, 11 (52%) were from a public inquest. No recommendation was made following any of the 45 single heavy vehicle crashes.
Conclusion: The frequency of coroners' recommendations varied by crash nature including vehicle type involved and number of resulting fatalities. Multiple factors are likely to influence their development, including the holding of a public inquest and the perceived level of preventability.
Implications: Coroners' investigations serve an important public health and safety role. Recognition of the significance of recommendations for reducing the extent of injury from heavy vehicle crashes and monitoring of their uptake is vital.