Kerryn Butler
Dr Kerryn Butler is Principal Researcher at the Law and Justice Foundation of NSW, where she leads applied social science research on access to justice, legal need, and program evaluation. She holds a PhD in Public Health and a Master's in Social Health and Counselling, and is a conjoint researcher with the University of Technology Sydney's Faculty of Law. Kerryn is a mixed-methods researcher and sits on the Justice Health & Forensic Mental Health Network Human Research Ethics Committee. Her work informs policy and service design aimed at improving access to justice for disadvantaged and marginalised communities.
Session
Coronial investigations occupy a neglected position within access to justice scholarship. While coronial proceedings offer important procedural protections for bereaved families, the preventive function of the coronial jurisdiction, (its capacity to generate recommendations that drive legislative, regulatory and policy reform) has received limited empirical attention. Whether recommendations actually translate into meaningful change is a question of accountability and distributional justice: it goes to whether the justice system delivers on its preventive mandate for communities most exposed to preventable harm.
Existing research has primarily evaluated coronial recommendations through implementation or acceptance rate frameworks, examining whether the agency to which a recommendation was directed formally accepted, rejected, or partially implemented it. While these approaches yield useful descriptive information, they implicitly assume a relatively linear relationship between recommendation and documented reform. In practice, policy changes rarely follow such a pathway. Reforms addressing risks identified in coronial investigations frequently emerge through extended policy processes (government reviews, commissioned research, regulatory consultation and incremental legislative development) that may unfold over years following the original recommendation. Recommendations may also contribute to change indirectly by shaping policy agendas, informing research, or reinforcing concerns raised through parallel policy processes. No established method exists capable of systematically tracing these broader non-linear pathways of influence. The From Inquest to Impact project therefore required constructing a new analytical framework from the ground up.
This presentation introduces Recommendation-to-Reform Mapping (R2R Mapping), a structured qualitative method developed to trace policy influence of coronial recommendations over time. The method integrates documentary policy analysis, policy sequence analysis and process tracing to reconstruct the sequence of policy developments that may follow from coronial findings. Rather than evaluating recommendations by whether they were formally accepted or rejected, R2R Mapping traces the broader policy trajectories through which coronial findings may contribute to institutional and legislative change.
The method involves five analytical stages: defining the policy domain; identifying and coding coronial recommendations; identifying relevant policy developments and reforms through systematic documentary analysis; constructing chronological policy timelines; and assessing linkages between recommendations and reforms. Linkages are classified according to both type – direct, indirect, or conceptual agenda-setting, and strength of evidentiary support. This structured approach enables recommendations, reforms and policy linkages to be systematically compared across policy domains, time periods, and institutional actors.
The method is illustrated through its application to the rock fishing safety domain, one of a number of preventable death domains examined in the From Inquest to Impact study, commissioned by the NSW State Coroner. This domain provides a concrete example of how the framework records intermediate policy developments events, such as commissioned research and safety reviews, alongside substantive legislative reform, and assess the documentary evidence linking coronial recommendations to each. The rock fishing safety domain also demonstrates the potential to integrate R2R Mapping with quantitative mortality trend analysis, enabling examination not only of how recommendations contributed to reform, but whether those reforms were followed by measurable reductions in preventable deaths.
The presentation considers both the methodological challenges of working in data-poor documentary environments, including the differential visibility of policy instruments and the inherent uncertainty in attributing reform to specific recommendations. The potential for R2R Mapping to be adapted for application to other investigative and oversight bodies that produce recommendations aimed at reducing preventable deaths is also discussed.