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 81 results

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 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

Inquest into the death of David Scott Freeman

CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reactio

Findings date: 21/02/2025

Inquest into the death of Daniel Munro Lewis Turnbull

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, natural causes, need to deliver treatment, 24 hour surveillance cell, RIT, mental illn

Findings date: 19/02/2025

Inquest into the death of Ms K

CORONIAL LAW – mandatory inquest, death of a person by homicide, coercive control, was response of NSW Police Force to reports of domestic and family violence

Findings date: 12/12/2024

Inquest into the death of Simon Cartwright

Correctional inmate, failure to observe signs of illness, failure to diagnose, peptic ulcer, natural causes, failure to identify illness, need to deliver treat

Findings date: 03/12/2024

Inquest into the death of Michael Peachey

Death as a result of police operation, First Nations death, restraint of person in the prone position, was the response of police and ambulance officers approp

Findings date: 28/11/2024

Inquiry into the fire at Yankees Gap Road, Bemboka

general inquiry, cause, origin and circumstances, hazard reduction burn on private property, Bush Fire Hazard Reduction Certificates, whether burn appropriatel

Findings date: 08/11/2024

Inquest into the death of Elizabeth Britton

Cause of death non accidental blunt force head injury- suspicious circumstances-open finding on manner of death-recommendation that NSW Police Unsolved Homicid

Findings date: 07/11/2024

Inquest into the death of Elizabeth Britton

cause of death non accidental blunt force head injury, suspicious circumstances, open finding on manner of death, recommendation that NSW Police Unsolved Homic

Magistrate: Carmel Forbes
Findings date: 07/11/2024
Case no. 2020/00324025
Recommendations to: New South Wales Commissioner of Police

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

Last updated:

18 Feb 2025