Hello Karyn,
Thanks for posting your replies. It must be so hard for you every time this issue comes up (and I know advocacy at systems level can be so frustrating)
I discovered the 'non-impact' of coroners recommendations when my son died of his overdose while a patient in a psychiatric ward. The coroner's had an investigation and then a formal inquiry (one step below the full out coroners inquest)
They came up with some amazing recommendations that would/could prevent this happening to another patient. In my 'naive-ness', I just assumed that those recommendation had to be implemented as a means of re-course to avoid other preventable deaths. Imagine my shock and dismay to learn that there is no governing body or any means to enforce the implementation of those coroner recommendations.
As you said Karyn, ..."so sad"
Betty-Lou Kristy
Lived Experience/‘Family’ Advocate- Mental Health, Addiction, Trauma & Bereavement