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Safer journeys for coroners

Safer Journeys is New Zealand’s road safety strategy to 2020, with the vision of a
‘safe road system increasingly free of death and serious injury’.

At the heart of Safer Journeys is the Safe System approach, which recognises that some error and some crashes are inevitable, but that deaths and serious injuries on the roads are not.

Overseas research indicates that even if all road users complied with all road rules, road deaths would only fall by about 50%. Our aim is to reduce the likelihood of human error and make the transport system more forgiving when errors occur. It is a fundamentally different approach based on working across all elements that contribute to road safety outcomes namely road users, the road and roadside, travel speed and the vehicle.

The Safe System principles are:

  1. People make mistakes and some crashes are inevitable.
  2. Our bodies don’t withstand crash forces well.
  3. System designers and system users must share responsibility for managing crash forces to a level that doesn’t result in death or serious injury.
  4. We need to strengthen all parts of the system: roads and roadsides, speeds, vehicles and users.

What does it mean for coroners?

This approach strongly supports and reinforces the coroners’ mandate to inquire
independently into the causes and circumstances of deaths, identify lessons to be learned and make recommendations to help prevent such deaths occurring in the future.

Coroners are important partners in creating a safer road system in a number of ways:

  • Ensuring that inquiries take a whole of system approach (roads and roadsides, vehicles, speeds, use).
  • Providing early warning of emerging road safety issues.
  • Identifying opportunities for road safety partners to work collaboratively to address emerging issues.
  • Providing a balanced public commentary on road safety issues which will help shape the road safety conversation in the media.

Safer Journeys aims to reduce death and serious injury

To prevent deaths and serious injuries, we try to predict where they are most likely to occur. Fatal crashes are rare and often random events relative to travel volumes. On average, there are seven deaths per billion kilometres travelled. Serious injuries are less rare and a better predictor of future risk (50 serious injuries per billion kilometres travelled). However, only 30% of fatal and serious crashes occur at a site where there has been any crash previously.

So undertaking specific improvements at such sites may not necessarily result in improving future safety outcomes. We need to take a wider system view.

Coronial findings are one of a number of important sources of information for road controlling authorities and other system designers in identifying risk and preventing road deaths and serious injury.

How we work with coronial findings

Changes to road safety policy and practice are generally made collaboratively at a sector level and serious crash reports have recently been redesigned to assist Coroners in identifying all of the factors that may have contributed to a death. All coronial recommendations are carefully considered along with research findings and should be sent directly to the agency where the recommendations are directed, with a copy also sent to the Chief Coroner. Refer to the Bench Book for more information.

Coronial findings provide impartial and in-depth analysis of individual crashes and are most helpful to inform future policy when they:

  • identify all the causal factors, including underlying system contributions such as:
    • the road and roadsides – both the road design and the standard of maintenance
    • whether the speed limits (or advisory signs) are appropriate for the road environment and whether the drivers/riders were travelling at the right speed for the conditions
    • the level of protection afforded by the vehicles involved (either vehicle in a two driver crash)
    • whether the driver or rider had a lack of skill, awareness, alertness or compliance
    • the adequacy and timeliness of the crash response
    • identify causes of the death without prejudging what the best solution is in this instance
  • have tested the recommended solutions with road safety experts as they are more likely to be robust and in line with best practice

  • point to emerging trends (which may prompt research) and generic factors. This may include situations or demographics that are emerging as high risk, or a recurring pattern of older vehicles, high speeds, unforgiving roads or roadsides, fatigue, distraction and prescribed drugs which contribute to the crash.

 System designers want to know about

Roads and roadsides

  • New Zealand’s topography is challenging and most roads evolved at a time when vehicles travelled more slowly.

  • While it’s not economically possible to upgrade all roads to the highest modern safety standards, it is helpful if coroners can identify recurring themes as they emerge, such as head-on crashes on high speed arterial roads, crashes into poles/trees and intersections in general.

  • These may assist road controlling authorities to think carefully about the focus of their infrastructure resourcing funding.


  • Speed is important in a Safe System because it is directly related to the severity of a crash and the injuries sustained.

  • For this reason, the speed of a crash is always of interest to crash investigators – even when the speeds travelled at were within the legal limits.

  • It may be that the limits were not appropriate for the road design or function.


  • All vehicles in a crash contribute to the likelihood and severity of the crash.

  • Where there are two vehicles involved in a crash, it is common to look just at the vehicle of the at-fault driver or rider. Sadly, it’s all too common for the other vehicle to also contribute in some way or to fail to protect its occupants.

  • Contributing causes to a crash or fatality in cars can include brakes, tyre tread, tyre pressure, suspension and steering, and these should be investigated, especially in older cars.

  • Modern cars are more likely to have electronic stability control and airbags, which add extra protection when a crash occurs. Their presence or absence might be worthy of note.


  • In a safe road system, we aim to protect all road users, even those who are acting unsafely – no one deserves to die, even if they may be breaking the law. 
  • It can be difficult to protect people who have a high tolerance for personal risk and where there are extreme speeds or levels of alcohol – but even in these cases it is helpful to know what other factors contributed to the fatality.

  • That’s why we aim to look beyond the driver and beyond blame – we want to know about levels of skill and alertness as well as compliance for all drivers. We are also interested in social factors, for example whether a workplace might influence behaviour such as time pressure on commercial drivers.

 Download Safer journeys for coroners [PDF, 1 MB]