It starts as something routine and academic-part of what I do for a living. I've been here many times over the years. It's now to the point that this office is familiar, but I still feel the responsibility and weight that comes with my arrival. A plaque at the front reads: "We speak for the dead to protect the living. " This statement was inspirational 15 years ago. Reading it now adds some trepidation and maybe a bit of guilt as I continue my work here: we have "spoken" for so many, but protected so few. Looking up from my seating area, I see rows and rows of stuffed filing cabinets, a paper trail of death. I smell formaldehyde. I am handed "the list" for the year, and armloads of files. Some of the files are very thin, with one-line reports and attending physician signatures. Others are thick and worn, and tied together with elastic bands that strain with the contents. I try to be efficient, and separate the kids' files into two stacks: those for children more than seven years old, and those for the very young. The younger kids' pile has twice the number. This strikes me as profound. I begin to read, and like always I become drained yet fascinated by the stories. They are all so graphic and so very sad. I am drawn into the horrors contained in the autopsy, police and ambulance reports, coroners' statements, and accounts of bystanders. The stories are always the same, over and over, to the point that I question if I'm reading the same files repeatedly. Another child crushed in a tractor runover, the same story of a drowning, the same mom or dad who was minding the kids while they got a few chores done, and "just turned their head for a moment." And from the coroners and police: "a freak accident within a well known family... so tragic... couldn't be helped... no inquest or inquiry, the family has already suffered enough. " I begin to feel torn up inside. I think of my own young children. To cope, I become clinical and rather analytical in my approach. There is no more pain and anguish, only check boxes, text descriptions, cross-tabulations, and recommendations. Then I feel even more guilt. These dead children are becoming numbers. The stories that I am re-living, including the forensic pictures, are all so horrible. There is so much grief. My eyes well up. I find that I am angry, but am not sure at whom-at farm parents who expose their children to risks, at a rural society that appears to accept these tragedies as part of their fate, at the coroners and health and safety professionals that have yet to challenge the status quo. This is no longer an academic exercise. Something must change.