The case studies show that the recommendations of the Royal Commission relating to custodial health and safety are often ignored by coroners and custodial officers. Moreover, they reveal the application of widely varying standards of acceptable custodial care from coroner to coroner. The use of this variable standard, coupled with an apparent reluctance by coroners to make recommendations for preventing similar custody deaths blunts the effectiveness of the coroner's work as a reliable means of identifying risk factors and developing remedial strategies. Possible reasons for coroners' reluctance to make recommendations regarding preventive measures are the historical background of the coroner's role; the narrow focus of coroners' investigations into custody deaths; possible conflicts of interest in the preparation of evidence for presentation at an inquest; the weakness of the legislative context; and legalistic "smokescreens" that obscure the development of preventive and consistent standards of custodial care. These factors skew the coroner's examination and draw attention away from a forward- looking systemic focus that could lead to useful remedial action. 3 tables and 17 references