Personal circumstances and health issues were behind Mabbutt's departure but it is no secret the former co-ordinating magistrate of Sydney's busy Central Local Court was a somewhat unconventional pick for the role. Loading He replaced Michael Barnes, who had a decade's experience as Queensland Coroner when he was appointed state coroner in 2014, and was a less likely successor to Barnes than experienced deputy coroner Teresa O'Sullivan, now acting state coroner. Mabbutt's replacement, who will help guide the future direction of the court, will not be appointed until after the March 23 state election. Meanwhile, a long-awaited statutory review of the NSW Coroners Act has yet to be released by the Berejiklian government. The election will have "momentous consequences for the coronial system in NSW", former deputy state coroner Hugh Dillon said in a paper delivered in Sydney this month.

He called for a "long-overdue root-and-branch reform of the system" and shift in focus to public health and safety rather than suspicious deaths, which are already investigated by the police. "The foundations of the current structure of the coronial system were laid down in 1901. In that year, steam engines – operating at 8 per cent efficiency – were high tech," he said. "Although some of the work of coroners relates to unsolved homicides and suspicious deaths, recent thinking about coroners emphasises their roles in enhancing public health and safety." Former deputy state coroner Hugh Dillon has called for a "long-overdue root-and-branch reform of the system". Credit:Sahlan Hayes Victoria has already trodden this path, with two waves of reforms in the 1980s and the early 2000s. Now, one of the explicit statutory purposes of the Coroners Court of Victoria is to "contribute to the reduction of the number of preventable deaths" through its findings and recommendations. One of the striking and little-known aspects of the NSW coronial system is that the state does not have a standalone, specialist coroner's court, as already exists in every other state but Tasmania. Instead, it uses a "hybrid" model, under the control of the Local Court, where six full-time coroners are employed in Sydney, and country and regional magistrates act as ad hoc coroners across the rest of the state. Dillon has previously said this is a "recipe for mediocre service". "While the current team of full-time coroners based at Lidcombe is an excellent group – possibly the best team NSW has ever had – our system as a whole is not designed for purpose," he said.

Dillon said recent inquiries aimed at trends rather than individual cases, such as the drug-related deaths of "doctor-shopping" patients and the recently announced inquest into deaths at music festivals, "tend to be the exception rather than the rule", especially in country areas. Loading Victorian barrister Dr Ian Freckelton, QC, a leading expert on coronial law, said the hybrid model in NSW "fails to recognise the unique nature and demands of the coroner's jurisdiction" and is "somewhat anachronistic now". He said there was "considerable governmental support" in Victoria for the Coroners Court, a stand-alone, specialist court in Melbourne. In 2008, when a new Coroners Act was passed giving the court an explicit mandate to prevent deaths, the government also established a Coroners Prevention Unit – the first of its kind in Australia – to assist the court to perform that function. The specialist unit supports coroners by providing advice on a range of issues, including "the frequency of previous similar deaths in Victoria, common risk factors ... [and] interventions that are proven or suspected to reduce the incidence of similar deaths", a court spokesperson said.

Freckelton said the unit assisted coroners to "contextualise individual cases in a broader system". The Victorian court is also assisted by the independent Victorian Institute of Forensic Medicine, which provides expert scientific and medical services underpinning the court's investigations. Freckelton said the Victorian system had "a number of features which can usefully be adapted" in NSW. Court resourcing was another fundamental issue, and "the funding of a larger number of coroners per capita is constructive". "The workload of the jurisdiction is very high and if it's to be done well it's time-consuming, meaning there need to be sufficient coroners and support staff to assist them," he said. Latest figures from the Productivity Commission show NSW's recurrent expenditure on coronial services was $6.6 million in 2017-18, compared to $16.7 million in Victoria and $11.3 million in Queensland. Victoria has 11 full-time coronial positions and Queensland has seven; there are six in NSW.

Dr Marc Trabsky, senior lecturer at La Trobe Law School and deputy director of the university's Centre for Health Law and Society, said "Victoria is held up as a model jurisdiction in Australia". The Coroners Court of Victoria is assisted by the independent Victorian Institute of Forensic Medicine. Credit:AAP He said the Coroners Court of Victoria and the institute, which has close ties to Monash University, work closely together and had shown a "capacity to handle mass deaths during the 2009 [Black Saturday] bushfires". Both were called on to go to the Netherlands to assist in the disaster victim identification process after the MH17 plane crash in 2014 and were "the port of call for the repatriation of the Australians who died tragically in that disaster". David Ranson, deputy director of the Victorian Institute of Forensic Medicine and its head of forensic services, said "the point that I often make is that death investigation is a political process".