The coroner's service is calling on the B.C. government to improve the oversight of commercial vehicles after reviewing the death of a young woman who fell from a party bus in Vancouver.

23 year old Chelsea James died on Jan. 9, 2016, after she fell against the vehicle's passenger door and it opened suddenly, causing her to tumble onto the street where she was struck by its rear tires.

Coroner Cynthia Hogan says in her report released Tuesday that the bus had a long history of door malfunctions and was issued with multiple repair orders, but a provincial oversight agency allowed it to keep operating despite receiving no proof of repairs.

She says a Vancouver police investigation following James's death found that the door could be opened while moving due to a combination of low operating pressure and a non-functional secondary locking mechanism.

The coroner recommends the Transportation Ministry implement a tracking system to ensure that all repair orders are documented and non-compliance results in appropriate action.

It should also create a quality management process for inspection facilities.