Automatic language translation
Our website uses an automatic service to translate our content into different languages. These translations should be used as a guide only. See our Accessibility page for further information.
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.
This is the archive page which hosts responses received between 2009 and 2022. Responses received from 2023 onwards can be viewed and searched on our updated website here.
NOTE: The Responses in the tables are detailed summaries. If you would like to have a copy of the actual Agency response, please contact Legal, Department of Communities and Justice.
This link is to a document that sets out Coroners' findings and recommendations by categories. It might assist if you are looking for recommendations in a particular area, for example, mental health, or transport.
Find the categories here.
Table containing responses to the Coronial recommendations in the Lindt Cafe Siege Inquest
Table containing responses to the Coronial recommendations in the Music Festival Deaths Inquest
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Adams T | 'EW' | 'LAK' | Roberts J |
| Bischard R | Facer A | Lester A | Samuel T |
| Braes A | Fackender I | Martin R | 'SB' |
| Bugmy K | Forrest K | Metcalfe C | Shillingsworth M |
| 'CD' | 'GH' | Morgan MD | Shortland R |
| 'CS' | Harrison M | Murphy M | 'SP' |
| Docherty S and S | Hayez T J | Peyret L | Tafau M |
| Eastcott D | Israeli Consulate and Hokoah Club fire and explosion | Powell C | Tauaifaga T |
| Ellis G | Ittivithchai C | Rae M | Yakamurro |
| Epere W | Knight K | Raichman A | 'ZA' |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| 'A' | Drabsch J | Mackander B | Spencer D |
| 'AJ' | Edwards J, J and J | Macri N | St John J |
| Aperahama PW | 'F' | Mavris D | Sutton H |
| Appleby KC | Goolagong I | 'MF' | Thompson GP and Walton T |
| Barwick U; Jones G; Daveson L; and Meier C | Gray T | 'MH' | Wepitiya-Gamage Y |
| 'Becky' (pseudonym) | Horne J | Ngo HN | Whitton D |
| Chrupalo J and Clee C | Kettule D | Reedy Swamp Tarraganda Bega/ Tathra fire | Wild M |
| Crough BJ | Kokaua J | Reynolds N | Wolf L |
| Cruz C | Laurenson JG | Richardson B | 'Z' |
| Diec Q | Loh J | 'S' | Zraika S |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Ahmad W | 'Channa' (pseudonym) | Flamish J | Morris J |
| Allam M | Chatfield T | Gore B | Ngo A |
| 'AP' | 'Chiu Y' (pseudonym) | Hogan J | Nutter J |
| Bohnenkamp K | Cook G | Hunt T | Redman T |
| Brockett H | 'DB' | Kline S | Robin P |
| Carroll B | Dominick B | 'LP' | Russell M |
| Cartwright JC | Donnelly R | Marsden R | Taha B |
| Cayirylys S | 'DP' | Mikic I | 'XY' |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Ah See T | Dungay D | 'Levai' | 'RN' |
| Al Refaay O | 'Edwards H' (pseudonym) | Lutz M and Manrique F Manrique E, and Manrique M | 'RP' and 'DJ' |
| Auton R | 'Emily' (pseudoynm) | Mackell K | Sekeres P |
| Battaerd H | Ewin K and O'Sullivan I | Maher R | Speechley R |
| Bell S | 'Flagview South' Sir Ivan Doherty Drive, Leadville fire | Martin R | Teasdale R |
| Blakeway G | Hellyer K | Maxwell M | Thomas P |
| Bourke X | Hill C | Metcalfe I | Wells N |
| Bugden A and Bestrin A | Hutchings G and Dorendahl E | Mokmool D | Williams N |
| Butler W | Kabbout M | Naudi T | Wright J |
| Clutton N | Kessell P | Opiate Overdose deaths | Yousif Y |
| Cruickshank J | 'L' | Pahiva E | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Amone M | Hoang P | 'MC' | Slager B |
| Bartholemeusz L | Hodge S | McDonald M | Springwood and Mount Victoria fires |
| 'BLNG' and 'DG' | Howard D | McGrorey-Smith J | Standen M |
| Burton-Ho A | Jeffrey C | Northern Beaches deaths | Teelow S |
| Campbell A | Jibba M | Peden T | Topic C |
| Chiang J | 'JT' | Pegum M | Tran Bui S |
| Cree S | Khawaji K | Perrin M | 'W' |
| Eberle K | Kirnawi S | Rana M | Woodcroft P |
| Fenika F (aka Togatuki F) | 'KS' | Richardson G | Wright, J |
| Fifi H | Lau P | 'RR' | 'XX' (Saha) |
| 'FW' | 'MA' | Russell G | Young C |
| Galea D | Mara A | Shortland S | |
| Henderson I | Martin Q | Singh K | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Alexander C | Collando H and Llanto C | Inmate 'P' | Parker C |
| Ashburn C | Currah B | Johnstone G | Peihopa R |
| Baker I | 'DT' | Kramer C | Pham T |
| Bale J | Erbacher J | Leveson M | Pou B |
| Bartholemew P | Gilligan B | Lobejko D | Raftery A |
| Barton J | Haenga E | 'MC' | Veech D |
| Black D | Handog E | Name Withheld | Walsh B |
| Browne D | Howlett K | Norris K | Webb C, MacDonald R and Wilson B |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| 2-4 Shaw Street, Petersham fire | Day K | Jung P | Rozs B |
| 'AXX' | Donnelly M | MacGregory A | Russell A |
| Baby 'Lily Grace' (pseudonym) | Drysdale S | Marsh H | Singh R and Thind S |
| Baby 'NA' | Fakhouria A | McDonall M | 'SS' |
| Boskovski V | Hickey B | Miller B | Tu T |
| Coghill E | Hookey S | Peisley F | Unknown Male Torso found at Botany Bay |
| Coote G | Johnson E and Joel K | Romeo I | Yildrimtekin S |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| 'AB' | Goldsmith M | Quad Bike deaths | Sukhov I |
| 'AC' | Govinden J | Quakers Hill Nursing Home fire | Tancevski M |
| 'AJ' | Gray P | Robson-Pearce W | Thomas M |
| Allibon G | 'GXM' | Rock Fishing deaths | Tran T and Karayiannis N |
| Baby 'RD' | 'GXW' | Rossington P and Schroder K | University of Technology, Sydney fire |
| Buckley P | Habib A | Sassine S | Vella D |
| Ciappara J | James L | Schlict J | Warrumbungle National Park (Wambelong Campground) fire |
| Domachuk P | 'JX' | Shillingsworth K | Wilson T |
| Foale K | King B | Sjostrand A | Yeoman S |
| 'GA' | Lenthall T | Southwick A | Young L |
| Gibson J | Lewis M | Srawn P | Zhang C |
| Gilks T | Martin J | Stace H | 'ZZ' |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| 'AA' | Maharaj R | Pierce D | Thomson J |
| Bowman C | Manners I | Raj H | Waterlow N and Heuston C |
| Brannigan T | Mawby K | Rosen M | Watson B |
| Burns B | McCabe H | Sajko R | Wilson M |
| Drake C | McGregor F | Salid C, Attard N, and Akhtar S | Wilson T |
| Duncan Y | McIntyre M | Shankaranarayana M | Wood L |
| Eatalia Restaurant, North Strathfield fire | Mitchell M | Singh M | |
| Evans C | Neill D | Small J | |
| 'HB' | Peadon T | Suppressed | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Biviano J | Howell R | Schwartz E and Wales M | Vega A |
| Boyd J | Le Marseny A | Scifleet C | Walker R |
| Clitheroe J and Tucker E | Menrath S, Fraser P, and Fraser D | 'SF' | 'WG' |
| Coller P | Menzel M | Stephenson P | Yang X |
| Gunton W | Peisley B | Srougi B | |
| Harris-Chavarria K | Pringle R | Van Rysewyk A | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Alma Road, Padstow fire | Ghaderni N | Plum J | Tran N |
| Bosevski S | Ighani K | Rae M | Verhoeven M |
| Crowe L | Kumar P | Rubbo G | Yarranabbie Road, Darling Point fire |
| El Hafiane A | Lomas G | Sem K | Yeter D |
| Fisher S | McVicar I | Slavkovic E | |
| | |||
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Cho R | Gurram V and Rampal A | Kitanovski D and Daoud A | Simmons M |
| Clarke E | Hadley B | Lacey T | 'SK' |
| Clifford L | Hamilton D | Laudisio-Curti R | Trefelis E |
| Comina B | Harman G | Ligteringen J | Whalan E |
| Cowie I | Haywood M | McIlquham M | Wilson M |
| El Kass E | Hostel deaths (Batts S, Takas I, Hudson D, Birks I, MacKellar D, and Ramzan M) | Nicol E | |
| Gerbich A | Howell V | Poole M, Unicomb J, and Yates G | |
| Gilbody K | Ivanoska H and Channell J | Sauer J | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Mr 'A' | Donnelley J | Johnson G | Pearce M |
| Beshay R | Elliot J | Kimber M | Pulver D |
| Bridge M, D and J; Carolan D | Ghelani D | McDonald V | Rodda M |
| Bourke R | Goss M | Moore M | Smith N and Munnerley S |
| Costin N and O'Donoghue S | Grainger H | Murphy B | Whalan EB |
| 'DB' | Jenkinson L | Parsons M | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Ahsin P | Davie L | Hill M | Nakad A |
| Ang N | Dibley S | Holcroft M | Ovadia R |
| Beech J | Dunningham B | Howse C | Poor A |
| Belim J | Fresco I | Illa H | Simpson K |
| Carpenter P | Froio F | Kelly M | Suppressed #1 |
| Chiundiza K | Gilbert C | Khananyah R | Suppressed #2 |
| Codner P | Gilsenan B | Locke M | Suppressed #3 |
| Coventry G | Godden G | Magro M | Suppressed #4 |
| Crickitt C | Griffiths T | Matovic M | Suppressed #5 |
| Cumbo L | Haigh A | McLennan P | Sutherland M |
| Dani J | Hawes M | Murphy K | Waugh S |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Adams T | Cook M and Kudrytch J | Lawler A | Ren T |
| Ah See N | Djordjevic J | Lopes-Kristen T | Rose K |
| Al Mayahi A | Drury J | MacKenzie W | Taylor H and McGuinness A |
| Brimble D | Groat G | McMahon S | Wang Q |
| Bryant H | Grimmer C | Morcom J | Weekes G |
| Chivas S | Haynes T | Morris M | |
| Clarke H | Hong A | Owens J | |
| Conyngham I | Kirchner A | Patten D | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| 'AK' | Coolin G and Grenfell R | Kelso G | Speering T and M |
| 'AM' | Coxell H | Kovacevic J | Suppressed #1 |
| Avouris C | Dennison J | Lynch J | Suppressed #2 |
| Behr C | Dimitrakopoulos N | McLean J | Szczepek J |
| Brauer P | Doering K | Nixon D | Taylor C |
| Bugmy K | Dragun C | Patience I | Wildman A |
| Capel M | Ford F | Roberts M | White M |
| Chan O | Harris C | Siriani H | Woodcock L |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Ahmadi E | Howlett C | Moran G | Suppressed #3 |
| Callaghan J | Infant Swimming Pool deaths | Murphy M | Suppressed #5 |
| Eagle P | Jamal (aka Raza) A | Pele I | Tupou M |
| Engert J, Blinn A, Moore S, and Innes M | Johnson J | Phan Au I | Walmsley D |
| Forrester M | Kennedy G | Rankin S | Wilson P |
| Forster M | Lawrence R | Semaan C | |
| Hogan P | Midson P | Suppressed #1 | |
Table containing Coronial Recommendations and Government responses
Inquests mentioned in this table
| Name | |||
|---|---|---|---|
| Ball J | Cohn E | Iredale D | Pay C |
| Berkhout J | De Andrade J | Jones R | Shipley A |
| Bridger N | Djordiic S | LJ Hooker, Newtown fire | Stace L |
| Carmichael K | Fontana N | Maina M | Suppressed Name |
| Chau C | Hare M | McCarron T | Whitton SC |
| Chung S | Howard Pyrotechnics fire | Palmer V | Worrad G |
Last updated: