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.



Search

Filters

Search results

Showing results 1 - 10 of 117 results

Inquest into the death of Dushyanthan Visvanathan

CORONIAL LAW - Death in custody - alcohol withdrawal - inadequate information - level of care provided.

Findings date: 05/09/2025

Inquest into the death of KBS

CORONIAL LAW – infant death – non accidental injuries – insufficient evidence to make a finding on manner of death – suspicious death

Findings date: 28/08/2025

Inquest into the death of Michael Black

CORONIAL LAW – death in custody – Parklea Correctional Centre – stab wound to the chest – use of gaol-made weapon – 18 inmates in holding cell – failure to sea

Findings date: 22/08/2025

Inquest into the death of Ashley Paull

Collision with truck whilst walking along highway; mental health in custody; release from police custody after detention for secondary drug test; schizophrenia

Findings date: 18/08/2025

Inquest into the death of Margaret June Mariani

CORONIAL LAW – complications of cholecystectomy surgery – grossly inadequate care and treatment provided at Forster Private Hospital – inadequate monitoring an

Findings date: 14/08/2025

Inquest into the death of Wilfred 'Whippy' Robert Williams

CORONIAL LAW – Discretionary inquest – death of First Nations man following emergency presentation to Cowra District Hospital – deceased did not wait during tr

Findings date: 14/08/2025

Inquest into the death of Allyson Bailey

Coronial inquest, death in hospital (not anticipated); interaction between provision of physical and mental health treatment, impact of Covid-19 on hospital ca

Findings date: 13/08/2025

Inquest into the death of Jacob

CORONIAL LAW - Child abuse, unexplained death of an infant, methylamphetamine, failure to protect child from harm, presentation to hospital with unexplained in

Findings date: 08/08/2025

Inquest into the death of Stephen James Douglas

CORONIAL LAW – mental health-homicide-community mental health treatment – mental health policy and practice

Findings date: 08/08/2025

Inquest into the death of Lathan Brown

CORONIAL LAW – Aboriginal death in custody, cause of death, timeliness of emergency response, adequacy of emergency response, health care whilst in custody, co

Findings date: 07/08/2025

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

Last updated: