Vision Zero for coroners

Understanding injuries on our road

Creating a safe road system requires understanding of what leads to death and serious injury on our roads.

Our aim is to reduce the likelihood of human error and make the transport system more forgiving when errors occur. The Safe System approach works across all elements that contribute to road safety outcomes, such as speed and infrastructure, vehicles and road user choices. 

What role can coroners play? 

Coroners play an important part towards creating a system that protects people from death and serious injury when mistakes occur. 

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

Safe System is the gold standard in road safety and underpins Road to Zero

The Safe System principles are:  

  • We promote good choices but plan for mistakes.
  • We design for human vulnerability.
  • We strengthen all parts of the road transport system.
  • We have a shared responsibility. 

Coroners are important partners in creating a Safe System

  • Ensuring inquiries take a whole of system approach and consider all factors and system failures that have contributed to the crash and the injuries sustained.
  • Providing early warning of emerging trends in 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. 

Road to Zero seeks to reduce death and serious injury by 40% in the next decade 

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 actual risk (50 serious injuries per billion kilometres travelled). However, only 30 percent of fatal and serious crashes occur at a site where there has been any previous crashes. Undertaking specific improvements at such sites may not result in improving future safety outcomes, so we need to take a wider system view. 

Coronial findings are one of several important sources of information for road controlling authorities and other system designers in identifying levels of 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. Fatal and serious crash reports have recently been redesigned to encompass all aspects of the Safe System and assist Coroners in identifying all the factors that may have contributed to a death.  

All coronial recommendations are carefully considered and supported by relevant research findings where appropriate. Recommendations should be sent directly to the relevant agency to whom 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 can help 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 appropriate speed for the conditions
    • the safety performance or level of protection afforded by the vehicles involved (all vehicles in a multi-vehicle crash)
    • the driver or rider’s level of skill, awareness, alertness or compliance
    • the adequacy and timeliness of the crash response teams.
  • Identify causes of the death without prejudging what the best solution is in this instance.
  • Test possible solutions with road safety experts to ensure they are robust and in line with best practice.
  • Point to emerging trends (which may prompt research) and generic factors - such as situations or demographics that are emerging as high risk, or recurring patterns of less safe vehicles, high speeds, unforgiving roads or roadsides, fatigue, distraction or prescribed drugs contributing to crashes. 

What system designers want to know about 

Infrastructure and speed

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

For this reason, the speed prior to a crash and the impact speed are always of interest to crash investigators – even when the speeds were within the legal limit. 

It may be that the speed limit is not appropriate for the road or intersection as Aotearoa New Zealand’s topography is challenging, and most of our roads originated from a time when vehicles travelled at slower speeds. 

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

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


All vehicles in a crash contribute to the occupants’ potential injury severity in the crash and a light vehicle’s safety rating provides an indication of its safety performance e.g. how well it can protect occupants in the event of a crash. 

When two or more vehicles are involved in a crash, it is common to only look at the vehicle of the driver or rider considered to be ‘at-fault’. However, sadly, it’s all too common for the other vehicle to also contribute in some way in failing to protect its occupants or other road users. 

Contributing causes to a crash or fatality in cars can include brakes, tyre tread, tyre pressure, suspension and steering, and the condition of all the vehicles should be investigated, especially in less safe cars. 

A vehicle's contribution to keeping occupants safe and reducing their level of injury in the event of a crash is determined by cabin integrity, side intrusion bars, air bags, headrests, and other passive safety features.

Modern cars are more likely to have active safety features, such as electronic stability control and emergency braking, which can help prevent crashes from happening. Their presence or absence of any safety features would be worth noting. 

Road user choices 

In a safe road system, we aim to protect all people.  We accept that people make mistakes sometimes and a moment of inattention or a lapse in judgement can result in a crash.  Those involved shouldn’t die or be seriously injured because they or someone else made a mistake.  

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.  To help road safety engineers and policy makers adapt other parts of the system to compensate for risky behaviour, it is helpful to know if these factors contributed to a fatality. 

Although we should always look beyond blaming individuals, we need to know about levels of skill and alertness as well as compliance for all those involved in crashes. We are also interested in other influences on behaviour, such as social factors and whether a workplace might influence behaviour through time pressure on a particular role.