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 51 - 60 of 81 results

Inquest into the death of BW

self-inflicted death; death after emergency removal of child by NSW Police pursuant to Children and Young Persons (Care and Protection) Act; adequacy of Police

Magistrate: Harriet Grahame

Findings date: 08/09/2023

Case no. 2020/116336

Recommendations to: Secretary Department of Communities and Justice, Commissioner of the NSW Police Force

Inquest into the death of Maureen Smith

Glen Innes District Hospital; Armidale Rural Referral Hospital; referral of medical practitioner to the Medical Council of NSW; signs of clinical deterioration

Magistrate: Harriet Grahame

Findings date: 23/08/2023

Case no. 2018/103054

Recommendations to: Medical Counsel of NSW, Glen Innes District Hospital, Hunter New England Local Health District, NSW Ambulance, Patient Transport Services

Inquest into the death of SH

death in custody; adequacy of care; knock up records; ability for family or NOK to contact Correctional Centres with welfare concerns of an inmate

Magistrate: Carmel Forbes

Findings date: 16/08/2023

Case no. 2020/22402

Recommendations to: Chief Executive Officer Corrective Services NSW, Chief Executive Officer Justice Health and Forensic Mental Health Network NSW

Inquest into the death of Matthew Grieve

death in custody; hanging; health problem notification forms; custodial mental health pathways

Magistrate: David O'Neil

Findings date: 15/08/2023

Case no. 2019/324097

Recommendations to: Corrective Services NSW, Justice Health and Forensic Mental Health Network

Inquest into the death of Andrew Stubbs

monitoring of blood lithium levels by General Practitioner; lithium toxicity; decision to commence Intermittent Haemodialysis; complications of dialysis treatm

Magistrate: David O'Neil

Findings date: 11/08/2023

Case no. 2020/253013

Recommendations to: South Western Sydney Local Health District

Inquest into the death of Simon Miles

death of a First Nations man while on a Compulsory Drug Treatment Order; whether his release to Stage 2.5 of the Community Drug Treatment Program was appropria

Magistrate: Elizabeth Ryan

Findings date: 08/08/2023

Case no. 2021/339043

Recommendations to: Commissioner of Corrective Services NSW; Chief Executive Justice Health and Forensic Mental Health Network

Inquest into the death of Peter Gretton

death in custody; cause and manner of death; metformin toxicity; renal impairment; care and treatment of inmate patient; vital sign observations; blood glucose

Magistrate: Derek Lee

Findings date: 01/08/2023

Case no. 2019/2380

Recommendations to: GEO Group Australia Pty Ltd