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Communities and Justice

Responses to Coronial Recommendations Archive

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.

Are you looking for Coronial recommendations relating to a specific area?

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. ​

Inquest into the deaths arising from the Lindt Cafe Siege 

Table containing responses to the Coronial recommendations in the Lindt Cafe Siege Inquest

Inquest into the deaths of six patrons at NSW music festivals

Table containing responses to the Coronial recommendations in the Music Festival Deaths Inquest

 

January 2022 - December 2022

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'

January 2021 - December 2021

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

January 2020 - December 2020

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'

January 2019 - December 2019 

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 W​right J
​Clutton N
 Kessell P Opiate Overdose
deaths		 Yousif Y​
​Cruickshank J
 'L' Pahiva E ​

January 2018 - December 2018

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​
 ​P​eden 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
  

January 2017 - December 2017 

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

January ​2016 - December 2016

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

January 2015 - December 2015

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'

January 2014 - December 2014

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
 ​

June 2013 - December 2013

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
 ​

December 2012 - June 2013

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 ​
  ​
    

June 2012 – December 2012

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 ​

December 2011 - June 2012

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
  

June 2011 - December 2011

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

December 2010 - June 2011

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 ​

June 2010 - December 2010

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

December 2009 - June 2010

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
  

July 2009 - December 2009

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:

24 Oct 2024