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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.
Death as a result of a police operation – 23(1)(c) and 27(1)(b) of the Coroners Act 2009 –diagnosis of drug-induced psychosis – diagnosis of substance abuse di
death as a result of fall from height, Queen Victoria Building, acute psychotic illness, adequacy of care and treatment provided by Prince of Wales Hospital, a
circumstances of accident and death, survivability, response by NSWPF to report of person missing, search and rescue, search urgency assessment forms, regulato
missing person, referral to NSW Police Unsolved Homicide Unit
First Nations death in custody, section 23 mandatory inquest, prisoner attempting escape during medical escort, shot by firearm discharged by correctional offi
failure of diagnosis, perforated duodenal ulcer, insufficient medical investigations, necessity of identification of First Nations status when providing medica
diagnosis of mental health condition; care and treatment provided, Community Corrections assessment prior to release on parole, service provision for parolee i
cause and manner of death; cardiac arrhythmia; Torsades de Pointes; medical prescription of methadone (Physeptone tablets); appropriateness of dosage, inductio
mandatory inquest, death of a First Nations man in custody, was custodial mental health care adequate, were cultural needs adequately met, was the transfer of
missing person in a remote area; death due to methamphetamine and buprenorphine use; heat and dehydration as contributing factors; police land search and rescu
If you have any enquiries, please contact the Department of Communities and Justice, Legal
18 Feb 2025