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 122 results

Inquest into the death of Simone Strobel

CORONIAL LAW – fresh inquest – unsolved homicide – death of German national in 2005 – previous inquest held in 2007 – ongoing police investigations in NSW and

Findings date: 06/11/2025

Inquest into the death of Amar Dk Kattola

CORONIAL LAW – cause and manner of death – unsolved homicide

Findings date: 05/11/2025

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 Baby MA

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 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 H G-M

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 Mathew Richard Lothian

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

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

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