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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 in custody; cause and manner of death; risk assessment; psychiatric assessment; mental health review; self-inflicted death; cell architecture; Metropolit
elective surgery; post operative care; Private Hospital; no take back policy; transfer to Public Hospital; delay in return to surgery
High Dependency Unit; psychiatric care; Nepean Hospital; self-harm in psychiatric ward; mentally ill person; reduction of hanging points; highlighting of event
death in police operation; gunshot wound inflicted by police officer; appropriateness of actions of NSW Police Force officers; adequacy of care and treatment p
police pursuit; death in police operation; decision to initiate police pursuit; relevance of seriousness of offending; conduct of driving; Safe Driving Policy
death in custody; self-inflicted death; hanging in correctional centre; requests for medical treatment; sleep apnoea; obtaining CPAP machines in custody; adequ
Responses to Coronial Recommendations
death in custody; mandatory inquest; cell placement; whether medical condition adequately managed
fatal shooting of a woman in 2004; perpetrator unable to be identified; referral to Unsolved Homicide Squad
maritime safety; safety standards for recreational vessels; certification of recreational vessels; product warnings for recreational vessels; code of conduct f
If you have any enquiries, please contact the Department of Communities and Justice, Legal
18 Feb 2025