737 Organisational responses and implementation of coroners’ recommendations among cases of drowning in Victoria Australia

<h3>Background</h3> Drowning is the third leading cause of unintentional mortality globally comprising over 230,000 deaths annually. In many industrialised countries, drowning deaths must be independently investigated by coroners. At the conclusion of these investigations, recommendations may be directed to organisations with the aim of preventing future deaths. Since 2009 all coroners’ recommendations directed to individuals and organisations in Victoria, Australia and the United Kingdom, required written responses with a statement of what action has or will be taken, and these responses are publicly available. <h3>Objective</h3> To describe the frequency of coroners’ recommendations on drowning, organisational responses received, and evidence of support and implementation of prevention strategies. <h3>Methods</h3> A quantitative cross-sectional design was applied to identify drowning cases in the Australian state of Victoria for the period 1 July 2015 to 30 June 2022. A review of coroners’ findings was independently performed by two reviewers to extract information on the presence of a recommendation. A review of the organisation’s response was also performed to extract information on evidence that the recommendation was supported, and the actions taken to implement the recommendation. Conflicts in data extraction were resolved via discussion. Descriptive statistical analysis techniques were performed to report frequencies and proportions. <h3>Results</h3> Victorian coroners completed 255 investigations on drowning during the study period. There were 39 (15.2%) drowning cases where coroners made one or more recommendations, totalling 78 recommendations. Coroners directed these recommendations to 24 separate organisations, totalling 82 recommendations (i.e. some recommendations were sent to multiple organisations). Responses were received by the coroner from organisations for 74/82 (90.2%) recommendations. In their responses, organisations indicated support for 38/74 (51.4%) of the coroners’ recommendations and partial support in a further 24/74 (32.4%). Organisations reported they had implemented the recommendation in 18/74 (24.3%), partially implemented the recommendation in a further 19/74 (25.7%) and was under consideration in 20/74 (27.0%). <h3>Conclusions</h3> This study provides evidence that coroners’ recommendations are largely supported by organisations directed and many can be implemented. Further work is required to determine whether recommendations implemented have an impact on reducing drowning.