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Do Coroners (sometimes) go too far?

Some Coroners make recommendations with wide-ranging implications, often based on just one or a handful of very specific cases. They should increase their policy skills or be a little more modest about their abilities

Risk of travelling by each mode relative to bus for children aged 5-16 years. Bus = 1. (data from Hensher)

Following an investigation into the death of a cyclist, a New Zealand Coroner has publicly called for hi vis clothing to be compulsory for all cyclists. Wellington Regional Coroner Ian Smith reckons it’s a “no brainer”.

Coroners undertake expert investigations into the circumstances surrounding deaths. They provide an invaluable service to the community in ensuring information about risks to life is drawn to the attention of government and the wider public.

Yet they sometimes – and seemingly increasingly – tend to make sweeping public policy recommendations based on the circumstances of one particular case. Moreover they tend to give insufficient weight to, or ignore entirely, basic concerns of policy-makers like costs vs benefits, practicality, equity implications, and community acceptability.

On Friday, New Zealand blogger Eric Crampton searched Google NZ with the words “Coroner recommends”. That exercise yielded a list of 22 cases where Coroners had made recommendations on matters of general public policy ranging from improved privacy controls to age restrictions on access to butane and other inhalants.

I’ve picked out the recommendations that seem to relate to development:

Coroner recommends that all farm houses be fenced off

Coroner recommends people wear hard hats when climbing ladders to prune trees

Coroner recommends that you should have to have a licence to rent a nail gun.

Coroner recommends clearing trees near train crossings.

Coroner recommends national manhole safety guidelines.

Coroner recommends helmets for riders of motorised skateboards.

Coroner recommends changes to design of future prisons

I don’t doubt there’s a good chance many of the deaths investigated would’ve been avoided if these Coronial recommendations had been implemented at the time.

But it’s not so obvious they’d all be good policy. Mr Crampton’s view is a fair number of the 22 sets of recommendations would “fail any reasonable cost-benefit test”. He says:

Mandatory high vis clothing for cyclists, licenses for nail guns, and mandatory skateboard helmets all seem exceptionally unlikely to pass any kind of ‘is this a reasonable policy’ test.

Of course many recommendations made by Coroners are appropriate. But in too many cases there’s little sense they think about the public policy implications of what they’re recommending.

This tendency to make policy in a vacuum – to extrapolate to the wider world from one highly specific case – isn’t confined to New Zealand. It happens here too and of course the media love it.

Last week The Age ran an editorial, Why don’t our children have seat belts in buses?, arguing that Victoria’s Minister for Transport, Terry Mulder, should make seat belts in school buses mandatory.

The leader writer drew authority from a March 2011 recommendation by the State Coroner, Heather Spooner. She investigated the deaths of three people in a bus accident in 2009 and “called for several changes to this state’s policies on seatbelts in buses” (I haven’t been able to read the reports because the links to them on the Coroner’s site haven’t worked for over a week).

Mandatory seatbelts in school buses would seem to be another “no-brainer”, surely?

Perhaps, but there’s more to it. We need to think about how effective they’d be and what they’d cost.

A study in the 1990s by Austroads found 24 children aged 5-17 years were killed while travelling to and from school by bus during three years studied. However only 2 of those children were killed while passengers in the bus.

The most dangerous part of bus travel for children is getting to and from the door to the bus, especially in the afternoon. That’s when they’re most likely to be hit by another vehicle, or by the bus.

Yet the main travel risk for children isn’t buses at all. A study by Professor David Hensher found it’s more dangerous for children to be driven, or walk or cycle, than travel by bus or train (see exhibit).

When exposure is accounted for (i.e. kms of travel), taking the bus is 1.4 times safer in terms of the risk of death or serious injury than being driven; 4.4 times safer than walking; and 55 times safer than cycling. Travelling by train is safest of all.

Just to drive the message home, here’re some statistics from the US:

Every year school buses carry some 24 million students and collectively travel more than 4 billion miles…..School buses have a rate of 0.2 deaths per 100 million miles traveled. The rate of deaths in automobiles is eight times higher……Over a span of 11 years, from 1994-2004, a total of 71 passengers on school buses died in crashes. In the year 2004 alone, traffic accidents killed 31,693 people travelling in cars and light trucks.

Fitting buses with seat belts is costly. In Western Australia, where seat belts are being phased-in over a ten year period, it costs $26,000 to install seat belts on a bus. However if structural changes are required in older buses, such as strengthening mounting points, it can cost up to $71,000.

The Age cites a ten year old estimate that it would cost between $440 million and $4 billion to retro-fit all buses in the country with seatbelts.

In states like Victoria without dedicated school buses, it would be necessary to retro-fit a large proportion of the State’s entire bus fleet because they’re used for multiple purposes.

Seatbelts could also present operational issues. On scheduled services, drivers could be obliged to check that all children who board have put on their seatbelt. That could slow down services and increase costs.

Mandatory seatbelts on buses might seem like a “no brainer”, but spending the money in other areas – like redesigning bus stops to make them safer, or building dedicated cycling infrastructure – would have a far greater impact in terms of lower child casualties.

Since money is always scarce, that would seem to be the real “no brainer”.

In fact if we follow “Coroner Logic”, it would be much safer for children if parents were compelled to drive them rather than permit them to walk or cycle.

The substitution of driving for active modes is probably a key reason for the enormous drop in the number of child pedestrians killed nationally each year between 1990 and 2000 (from 27 to 9) or seriously injured (from 360 to 213).

But that would ignore a host of issues associated with non-active transport. They include traffic congestion, emissions, pollution, obesity, and the possible long-term health implications for the children.

It would be possible in theory to design a bus that was fatality-free (or a plane for that matter) but the cost in terms of money and negative externalities would be ludicrous. There are diminishing returns in improving in-bus safety – far better to spend available funds on other improvements.

So far as the Wellington Coroner’s recommendation that cyclists be compelled to wear hi-vis clothing is concerned, it’s obviously very similar to the mandatory helmet law. There’s lots that needs to be thought about there – two key questions are: what’s the measured benefit of hi-vis?; what’s the deterrent effect?

Coroners should be less grandiose when thinking about what they can sensibly recommend (a change in legislation might be necessary). They need to be more concious of their limitations and put more effort into understanding the wider policy implications of their findings.

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  • 1
    Alan Davies
    Posted February 20, 2013 at 9:21 am | Permalink

    From TheMail Online:

    An insurance giant is appealing against paying up to £5million compensation to a schoolgirl left brain damaged in a car accident – because she wasn’t wearing a high-visibility jacket at the time.

  • 2
    hk
    Posted February 20, 2013 at 9:23 am | Permalink

    For people interested in comparing accident risks associated with travel mode choice, the 2002 article, “HOW SAFE ARE BUSES CARRYING SCHOOL CHILDREN? SUPPORTING EVIDENCE” by David A. Hensher is well worth a read.

  • 3
    Posted February 20, 2013 at 9:46 am | Permalink

    Coroners don’t make public policy though. I don’t have any problem with them saying “Hi-vis clothing should be worn by all cyclists”. I would have a problem with them campaigning hard to get it made into law without taking into the consideration the potential downsides. I’m not sure to what extent coroners were to blame for MHL (you knew it had to be brought up!) but I suspect it wasn’t all that great in the scheme of things.

  • 4
    Smith John
    Posted February 20, 2013 at 11:25 am | Permalink

    In relation to high vis clothing for cyclists –

    To extend the logic: all pedestrians should wear high vis clothing at all times. All road side poles should be wrapped in fluoro. All cars should be painted in fluoro colours (not a joke – quite often I realise I have seen a black car on a converging course a second later than I would have seen it if it had been white).

    This is basically blame-the-victim stuff, and should be strongly rejected. It is the absolute responsibility of motorists to look out for, see, and avoid colliding with the things around them.** That is why cars have headlights for driving at night.

    There is an important difference between saying ‘cyclists should be encouraged to wear hi vis clothing’ (reasonable) and ‘cyclists should be forced to wear hi vis clothing, and are responsible for their own fate if they don’t’ (not reasonable)

    If the insurance company succeeds in nailing contributory negligence on the unfortunate girl who wasn’t wearing hi vis clothing while walking along a country lane, then I look forward to seeing the case when the plaintiff is given contributory negligence because they were driving a black car not a yellow one.

    ** providing of course that the other things behave predictably and don’t jump out in your path.

  • 5
    Tom the first and best
    Posted February 20, 2013 at 2:13 pm | Permalink

    The graph claiming to show the comparative risks for travelling by different modes for those aged 5-16, actually seems to show the whole population`s risks because it is unlikely that there is a statistically significant number of public road car drivers and motorbike riders in the 5-15 category to provide for reasonable statistics.

    The actual death rate for public road drivers and motorbike riders aged 5-15 is likely to be significantly higher as they are mainly poorly trained and lack experience and supervision as they are breaking the law and also thus unlikely to have co-operated with traffic surveys. The 16 year old drivers with L-plates and supervision would represent somewhat of a counterbalance to this but I doubt it would make the statistics the same.

    Retrofitting seatbelts to buses is unlikely to help but it is reasonable to fit them to new buses.

  • 6
    Alan Davies
    Posted February 20, 2013 at 2:22 pm | Permalink

    Tom the first and best #5:

    The graph is based on Table 5 in Hensher (How safe are buses carrying school children? Supporting evidence) that I’ve linked to in the text. Hensher’s Table 4 says car drivers aged 5-16 account for 0.2% of all pkm for this cohort, but 2.5% of their casualties.

  • 7
    john2066
    Posted February 21, 2013 at 2:52 pm | Permalink

    This article sounds right – most Coroners are just pompous members of the legal lunch club – the rotating door of elite government appointments. They neither live, nor understand, the real world, and their recommendations are often living in cloud cuckoo land.

  • 8
    Posted February 21, 2013 at 3:59 pm | Permalink

    Unlike the recommendations of hard-core libertarians that seem to have reasons for abolishing every regulation ever introduced? (not saying you are one, but it is the sort of comment they tend to make)

  • 9
    billie
    Posted February 21, 2013 at 5:26 pm | Permalink

    What can I say?

    One 5 seperate occasions last year I narrowly avoided running down cyclists wearing dark clothing, riding unlit bicycles before dawn. I avoided the shadow flitting across the windscreen, or noticed the spokes glinting in the headlights.

    I object to being assaulted by tourism ads played loudly as I swing from a handle on a Skybus at 10pm as it hurtles down the Tullamarine Freeway at 100km/h

  • 10
    Posted February 21, 2013 at 5:57 pm | Permalink

    I wouldn’t have any problem with a law requiring cyclists to be “easily visible” at night, over and above the already mandatory requirement for lights.

  • 11
    Alan Davies
    Posted February 21, 2013 at 6:14 pm | Permalink

    billie #9,Dylan Nicholson #10:

    I saw three cyclists in dark clothing close to the Westgarth cinema last night. One had no lights at all.

    Interesting to ponder though what a shared street would have to be like if one constraint was cyclists didn’t wear visible clothing at night or even legally have to have lights. Drivers would have to be a lot more careful.

  • 12
    Krammer56
    Posted February 22, 2013 at 6:09 pm | Permalink

    And how about “banning lane changing in tunnels” becuse one irresponsible truck driver was doing 20km/h over the speed limit and not watching where he was going. As if banning lane changing would have made any difference to that driver!

    Not to say it might not have merit – but not on the facts of that case.

  • 13
    puddleduck
    Posted February 23, 2013 at 3:20 am | Permalink

    Alan Davies writes: “Coroners should be less grandiose when thinking about what they can sensibly recommend (a change in legislation might be necessary). They need to be more concious of their limitations and put more effort into understanding the wider policy implications of their findings.”

    Methinks you’re overreaching yourself here too – it is not the role of a Coroner to do research into every area of public policy – coronial hearings would never end if this were the case. It’s the role of a Coroner to investigate a death (or multiple deaths – sometimes they ‘batch’ cases raising the same or similar issues) and make reocmmendations. It is then for the Executive to do the research, consider the recommendations, and decide what to do.

    Coroners perform an important role in society – for the individual/s who died, their families, and broader society. Significant reforms have been undertaken over time to make the coronial process a kinder one for families of the deceased.

    With all due respect, this article misses its mark.

  • 14
    Alan Davies
    Posted February 23, 2013 at 9:32 am | Permalink

    puddleduck #13:

    Coroners recommendations are influential. They get wide coverage in the media, are parlayed by interest groups, and put pressure on governments.

    Coroners can’t simply make recommendations with wide public policy recommendations without understanding the wider implications. Either they lift their game in policy analysis or they narrow their ambitions.

  • 15
    Chris B
    Posted February 24, 2013 at 7:37 pm | Permalink

    Increasing the regulatory burden of cycling, skateboarding, commuting, dogwalking, pedestrian skylarking or frolicking without wearing high visibility bubblewrap would massively discourage both children and adults from performing regular exercise.

    I’m wondering if the increased mortality from cardiovascular disease this policy would cause was factored into the coroners report?

  • 16
    Alan Davies
    Posted February 25, 2013 at 9:17 am | Permalink

    SMH’s On Yer Bike blogger, Michael O’Reilly on The benefits of being a colourful cyclist

  • 17
    Socrates
    Posted February 28, 2013 at 10:27 am | Permalink

    Alan you raise a good point here, and it is not a new problem. I think the worst example was years ago when there was an inquiry into a multiple fatality bus crash on the Pacific Highway, which led to a recommendation to four lane the whole thing, costing billions. The work has dragged on for decades, it still isn’t finished, and funds have been starved for upgrading or even maintaining the parallel rail links. But should we be doing it at all?

    The reality is the Pacific Highway is a long road, busy around coastal cities, very quiet in other sections. Why four lane the whole thing? Why not a Swedish style road with a wire rope down the middle? Why not just enforce driving regulations on bus drivers? Why not fix regional rail services as an alternative? The coroner didn’t consider any of those things.

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