Communities and Justice

Responses to Coronial Recommendations

The Coroners Act 2009 allows a coroner to make recommendations as part of their findings following an investigation into a death, suspected death, fire or explosion. Coronial findings are available on the Coroners Court Website.

In some inquests and inquiries, recommendations are made. Where recommendations are made to NSW Ministers and Government Agencies, they are required to report to the Attorney General within six months of receiving a coronial recommendation in accordance with Premier's Memorandum 2009-12, outlining any action to be taken to implement the recommendation. 

The Department of Communities and Justice maintains and publishes coronial recommendations and the subsequent responses.

You can view recommendations and any responses received via the search field.

Responses received between 2009 and 2022 are presently maintained on our Archive page.



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Showing results 1 - 10 of 199 results

Inquest into the death of PE

CORONIAL LAW – Death in custody – Parklea Correctional Centre - self-inflicted death – hanging points in custody – provision of telephone calls in custody

Findings date: 01/05/2026

Inquest into the disappearance and suspected death of Youliang Lin

CORONIAL LAW – whether missing person now deceased, date and place of death, cause and manner of death, Eric Mobbs Reserve, Ted Horwood Reserve, LandSAR Coordi

Findings date: 10/04/2026

Inquest into the deaths of Noah Smith and Wayne Smith

CORONIAL LAW – filicide – intentional self-harm – domestic and family violence – use of licensed firearm – history of anxiety and depression – NSW Firearms Reg

Findings date: 30/03/2026

Inquest into the death of Ronen Veinstein

CORONIAL LAW – Missing person, suspicious circumstances, referral to the Unsolved Homicide Squad

Findings date: 20/03/2026

Inquest into the death of Eve Liza Brown

CORONIAL LAW - First Nations - medical - regional health – delayed transfer - Lightning Ridge Multi-Purpose Health Centre - hypovolaemic shock - splenic haemat

Findings date: 19/03/2026

Inquest into the death of Gia Lim

Midwifery Support Program (MSP); early discharge of mothers and babies; sepsis; undiagnosed UTI; use of interpreters.

Findings date: 17/03/2026

Inquest into the death of Serena Lee

CORONIAL LAW - Midwifery Support Program; early discharge of babies; consultation as between doctors and midwives on neonatal wards; hyperglycaemia; intrauteri

Findings date: 17/03/2026

Inquest into the death of Gregory Merriman

CORONIAL LAW – mandatory inquest – death of a First Nations man in custody – use of force event in response to other inmates fighting in a POD – deployment of

Findings date: 06/03/2026

Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

CORONIAL LAW – cause and manner of death, dysphagia risk, choking risk, residential aged care facility, chewing and swallowing, International Dysphagia Diet St

Findings date: 27/02/2026

Inquest into the death of Jeremy Webb

Mammalian Meat Allergy after tick bite-awareness in hospitals and in the community-cause of death-severe allergic reaction-anaphylaxis-asthma

Findings date: 26/02/2026

If you have any enquiries, please contact the Department of Communities and Justice, Coronial Recommendations

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