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 92 results

Inquest into the death of DB

Infant death – homicide – non-accidental injuries – FACS – Family and Community Services – DCJ – Department of Communities and Justice – risk of serious harm r

Findings date: 01/05/2025

Inquest into the death of Colin Neil Amatto

CORONIAL LAW - Dog attack - examination of the Companion Animals Act 1998 regulatory regime - recommendations for regulatory change

Findings date: 16/04/2025

Inquest into the death of GP

CORONIAL LAW - Mental health - abscondment from mental health facility - hospital care and treatment - police response to abscondment - ADHD - Vyvanse - manner

Findings date: 31/03/2025

Inquest into the death of NL

CORONIAL LAW – Cause and manner of death, cardiac arrythmia, QT prolongation, hypothyroidism, compliance with thyroxine medication, endocrine management, thyro

Findings date: 28/03/2025

Inquest into the death of Michelle Daphne Michell

CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - cross

Findings date: 28/03/2025

Inquest into the death of Fiona Goodberg

CORONIAL LAW – manner of death, intentionally self-inflicted death, mental health diagnosis, mental health assessment, subacute mental health care, postpartum

Findings date: 25/03/2025

Inquest into the death of Fiona Turnbull

CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information ex

Findings date: 06/03/2025

Inquest into the death of Muhammad Hafizuddin Bin Zaini

CORONIAL LAW - Death of person in immigration detention – self-inflicted intentional death – was mental health care adequate – were there adequate communicatio

Findings date: 06/03/2025

Inquest into the death of Leah Jane Porter

CORONIAL LAW – Death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – approp

Findings date: 06/03/2025

Inquest into the death of Alan James Green

CORONIAL LAW – Death as a result of police operations; NSW police application of policies and procedures in relation to motor vehicle pursuits.

Findings date: 28/02/2025

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

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