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 31 - 40 of 81 results

Inquest into the death of Michael Murray

death in police operation, death as a result of a fall from height, borderline personality disorder, BPD, Dialectical Behaviour Therapy, DBT, Blue Mountains Ho

Magistrate: Erin Kennedy
Findings date: 17/04/2024
Case no. 2020/315984
Recommendations to: NSW Health

Inquest into the death of baby Everett Carleton

cause and manner of death of a baby at birth-ultrasound report, continuous CTG monitoring caesarean section, separation of the umbilical cordtransected placent

Magistrate: Carmel Forbes
Findings date: 12/04/2024
Case no. 2018/245959
Recommendations to: Director South Western Sydney Local Health District

Inquest into the death of Saso Ristevski

cause and manner of death; homicide

Magistrate: Teresa O'Sullivan
Findings date: 09/04/2024
Case no. 2011/388406
Recommendations to: Commissioner of NSW Police

Inquest into the death of Todd McKenzie

death in police operation; gunshot wounds by police officer; appropriateness of actions of NSW Police Force officers; use of “breach and hold” in a police oper

Magistrate: Harriet Grahame
Findings date: 05/04/2024
Case no. 2019/239447
Recommendations to: Commissioner of the NSW Police Force

Inquest into the death of Monika Chetty

cause and manner of death, open finding as to manner, cause of death acid burns, application of acid by another, immigration fraud, gambling, debts

Magistrate: Elaine Truscott
Findings date: 28/03/2024
Case no. 2014/3316
Recommendations to: NSW Commissioner of Police

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season

report on findings and recommendations made in 41 inquiries in respect of more than 110 reported fires and 25 deaths resulting from those fires during the 2019

Magistrate: Teresa O'Sullivan
Findings date: 27/03/2024
Case no. 2021/224481
Recommendations to: Commissioner of the NSW Rural Fire Service, Commissioner of the NSW Police Force, Chief Executive Officer Essential Energy

Inquest into the disappearance of Luke Huggard

unexplained disappearance and whether missing person is now deceased, date and place, cause and manner of death

Magistrate: Joan Baptie
Findings date: 22/03/2024
Case no. 2018/56509
Recommendations to: Executive Officer Prince of Wales Hospital

Inquest into the death of Brandon Rich

death in a police operation; adequacy of response to domestic violence incident; direction and detention pursuant to s 89A of the Crimes (Domestic and Personal

Magistrate: Harriet Grahame
Findings date: 21/03/2024
Case no. 2021/369343
Recommendations to: Commissioner of the NSW Police Force

Inquest into the death of Jasmynd Gibbs

death due to complications of methylamphetamine use; death of a person on supervised parole; wrap around support for parolees with complex needs

Magistrate: Harriet Grahame
Findings date: 20/02/2024
Case no. 2021/129807
Recommendations to: Commissioner of Corrective Services NSW, Secretary Department of Communities and Justice

Inquest into the death of Omar Mohammad

death in custody; acute cocaine toxicity; first aid by police; adequacy of NSW Police first aid training; CPR; NSW Police access to automatic external defibril

Magistrate: Harriet Grahame
Findings date: 19/02/2024
Case no. 2022/277315
Recommendations to: Commissioner of the NSW Police Force

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

Last updated:

18 Feb 2025