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 21 - 30 of 81 results

Inquest into the death of Charles Yan

death from drug overdose of a person in correctional centre; was supervision of inmates adequate; was emergency response appropriate; question of recommendatio

Magistrate: Elizabeth Ryan
Findings date: 03/07/2024
Case no. 2018/328285
Recommendations to: Commissioner of Corrective Services NSW

Inquest into the death of Ada Holland

coronial law

Magistrate: Carmel Forbes
Findings date: 14/06/2024
Case no. 2020/97395
Recommendations to: Chief Executive Officer Shoalhaven City Council, Office of Local Government

Inquest into the disappearance and suspected death of Florabella Remakel formerly known as Marion Barter

long term missing person; whether missing person is deceased; whether findings with regards to identity, date, place, cause, and manner of death can be made; n

Magistrate: Teresa O'Sullivan
Findings date: 12/06/2024
Case no. 2019/306081
Recommendations to: NSW Commissioner of Police

Inquest into the death of Mohamed Warwar

death in custody; natural causes; HPNFs; record keeping; communication between correctional officers and nursing staff

Magistrate: David O'Neil
Findings date: 21/05/2024
Case no. 2021/302441
Recommendations to: Acting Commissioner of Corrective Services NSW, Chief Executive Justice Health and Forensic Mental Health Network

Inquest into the death of Vicki Higgins

death in custody; cause and manner of death; ischaemic bowel; death during COVID-19 outbreak at Junee Correctional Centre; adequacy of care; adequacy of respon

Magistrate: Carmel Forbes
Findings date: 17/05/2024
Case no. 2022/27663
Recommendations to: Commissioner of Corrective Services NSW

Inquest into the death of Roger Schnelle

Diagnosis of mental health condition; psychotic depression / depression with psychotic features; care and treatment provided during admission at Nolan House in

Magistrate: Erin Kennedy
Findings date: 16/05/2024
Case no. 2021/122654
Recommendations to: Chief Executive Officer Albury Wodonga Health

Inquest into the death of Finlay Browne

mid-gut volvulus and bowel obstruction; ischaemic bowel; unconscious bias; consideration of disability and treatment in hospital; Bathurst Base Hospital; adequ

Magistrate: Erin Kennedy
Findings date: 10/05/2024
Case no. 2018/17393
Recommendations to: Western NSW Local Health District, Syndey Children's Hospital Network

Inquest into the death of Keith Titmuss

cause and manner of death; exertional heat stroke; exertional heat illness; hyperthermia; seizures; National Rugby League; Heat Policy; Manly Warringah Sea Eag

Magistrate: Derek Lee
Findings date: 03/05/2024
Case no. 2020/333632
Recommendations to: National Rugby League, Manly Warringah Sea Eagles

Inquest into the deaths of Mona Lisa and Jacinta Smith

Aboriginal; First Nations; Wakamurra; Muruwari; Kunya; Bourke; Enngonia; single vehicle collision; rollover; inquest resumed; s.79 Coroners Act; colonisation;

Magistrate: Teresa O'Sullivan
Findings date: 23/04/2024
Case no. 2022/27663
Recommendations to: Commissioner of the NSW Police Force

Inquest into the death of Baby Q

manner and cause of death; mental illness; family violence and neglect; family known to the NSW Department of Communities and Justice and the QLD Department of

Magistrate: Harriet Grahame
Findings date: 18/04/2024
Case no. 2018/359588
Recommendations to: QLD Director-General Department of Child Safety Seniors and Disability Services, NSW Secretary Department of Communities and Justice, Commissioner of the NSW Police Force, Commissioner of the QLD Police Service

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

Last updated:

18 Feb 2025