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 61 - 70 of 81 results

Inquest into the death of GS

cause and manner of death; death in custody; mental health; Justice Health waitlists; PAS; complying with patient waitlist timeframes; access to medical practi

Magistrate: Erin Kennedy
Findings date: 14/07/2023
Case no. 2018/281398
Recommendations to: Corrective Services NSW, Justice Health and Forensic Mental Health Network, St Vincent's Correctional Health, GEO Group Australia Pty Ltd

Inquest into the death of RRC

First Nations death in custody; adequacy of treatment and care; RIT discharge summary documentation; cell placement after a RIT; follow up after RIT; RIT model

Magistrate: Carmel Forbes
Findings date: 06/07/2023
Case no. 2021/317032
Recommendations to: Chief Executive Officer Corrective Services NSW

Inquest into the death of JY

acute psychotic episode; schizophrenia; was mental health care appropriate; recommendation to expand REACH program in public mental health settings

Magistrate: Teresa O'Sullivan
Findings date: 05/07/2023
Case no. 2018/180472
Recommendations to: Chief Executives of all Local Health Districts in NSW

Inquest into the death of SG

death of Aboriginal child; intentionally self-inflicted; protective care and treatment; recommendations made

Magistrate: Erin Kennedy
Findings date: 25/06/2023
Case no. 2020/144089
Recommendations to: NSW Department of Education, Department of Communities and Justice, Child and Adolescent Mental Health Service, Hunter New England Local Health District

Inquest into the death of Baylen Pendergast

suspicious death of a child; cause and nature of paediatric head injuries; whether head injuries were non-accidental; care provided at Tamworth Base Hospital;

Magistrate: Derek Lee
Findings date: 23/06/2023
Case no. 2013/361922
Recommendations to: Chief Executive Officer Hunter New England Local Health District

Inquest into the death of Brandon Clark

death in police operation; stop and search; section 21 LEPRA, exercise of power to arrest; section 77 Bail Act 2013; breach of bail; decision to engage in foot

Magistrate: Erin Kennedy
Findings date: 16/06/2023
Case no. 2022/20548
Recommendations to: NSW Commissioner of Police

Inquest into the death of CJ

death in custody; mandatory inquest; adequacy of treatment and care; opportunity for family to raise concerns about the welfare of inmates and patients while t

Magistrate: Carmel Forbes
Findings date: 06/06/2023
Case no. 2021/2579
Recommendations to: Chief Executive Justice Health and Forensic Mental Health Network, Chief Executive Officer Management and Training Corporation Pty Limited

Inquest into the death of Benjamin Woodhouse

mental health; involuntary patient; escorted leave; conditions of leave

Magistrate: David O'Neil
Findings date: 26/05/2023
Case no. 2020/21513
Recommendations to: AFEA Care Services Pty Ltd, North Sydney Local Health District, Commissioner of Police, Primary Care and Community Service

Inquest into the death of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins and Gareth Morgan

cause and manner of death; aviation fatality; de Havilland Canada DHC-2; Jerusalem Bay; Sydney Seaplanes; Airag Aviation Services; floatplane; engine exhaust s

Magistrate: Derek Lee
Findings date: 26/05/2023
Case no. 2018/1389, 2018/1393, 2018/1398, 2018/1399, 2018/1401, 2018/1404
Recommendations to: Chief Commissioner Australian Transport Safety Bureau, Chief Executive NSW Health Pathology, Chief Executive Officer Airag Services Pty Ltd; Chief Executive Officer Civil Aviation Safety Authority

Inquest into the disappearance and suspected death of Melissa Caddick

disappearance of a person; is the person deceased; if so can cause and manner of death be established; was the person suffering a psychiatric condition or diso

Magistrate: Elizabeth Ryan
Findings date: 25/05/2023
Case no. 2021/50376
Recommendations to: NSW Police Force

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

Last updated:

18 Feb 2025