Home - Communities and Justice - NSW Government Logo
Communities and Justice

​Government Responses to Coronial Recommendations

Premier's Memorandum 2009-12, Responding to Coronial Recommendations, was introduced in 2009.

You can read Premier's Memorandum 2009-12 here.

It sets out the process for Ministers and Government agencies to respond to recommendations made by the Coroner. The Memorandum is there to ensure that there is consistency in reporting what agencies and Ministers are doing in response to recommendations directed at them by the Coroner.

Agencies and Ministers are required to report to the Attorney General, within six months of receiving a coronial recommendation, outlining any action to be taken to implement the recommendation.

Not all inquests will result in the Coroner making recommendations. Recommendations may also be made to non-Government bodies, which are not required to report to the Attorney General.

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.

View Coroners' Findings and Recommendations

You can view the NSW State Coroner's findings and recommendations at this link, which takes you to the NSW State Coroner's Court.

Coronial Fi​ndings

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 2024 - December 2024

Table containing responses to Coronial Recommendations 

Inquests mentioned in this table

                                                                                                 Name
Garner T Huggard L Remakel F 
(aka Barter M)		               
Gibbs J Mohammad O Rich B              












January 2023 - December 2023

Table containing responses to Coronial Recommendations (DOC, 704.5 KB)

Inquests mentioned in this table

​Name
Beeby A Copeland G Hermiz A Roberts R
Bowden E & Ors 'DP' Higgins D ​​'RRC'
Button R Edmunds W Hope B Russell SL
'BW' Fernandez L 'JY' 'SG'
Caddick M  Gilbert A 'KT' 'SH'
Carr J Gretton P 'LT' Smith MA
Cawthorne S Greive M Miles S Stubbs A
'CC' 'GS' O'Donnell J Stark A
'CJ' Hamawy Z Pendergast B Woodhouse B
Clark B






January 2022 - December 2022

Table containing responses to Coronial Recommendations

Inquests mentioned in this table

​Name
​Adams T
 Epere W
 Knight K ​​Samuel T​
Bischard R
 Fackender I
 'LAK' ​​'SB'
Braes A
 Facer A
 ​Lester A Shillingsworth M
Bugmy K
 Forrest K
 Metcalfe C Shortland R 
'CD'
 ​​'GH' Morgan MD 'SP'​
​'CS' Harrison M ​​Powell C Tauaifaga T
Docherty S and S Hayez T J Rae M Yakamurro
Eastcott D Inquiry into the
fire and explosion
at the Israeli
Consulate and
Hokoah Club		 ​Raichman A 'ZA'

January 2021 - December 2021

Table containing responses to Coronial Recommendations

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 responses to Coronial Recommendations

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 responses to Coronial Recommendations (DOC, 798.0 KB)

Inquests mentioned in this table

​Name
​Ah See T
 ​​'Edwards H'
(pseudonym)		 Lutz M and Manrique F
Manrique E, and
Manrique M
 Sekeres P
​Al Refaay O
 ​'Emily'
(pseudoynm)		 Mackell K​
 ​Speechley R
Autton R
 Ewin K and
O'Sullivan I
 ​Maher R
 Teasdale R​
​Battaerd H
 ​​'Flagview South'
Sir Ivan Doherty
Drive, Leadville fire		 ​​Martin R
 ​​Thomas P
​Bell S
 ​​Flood-Smith M
 Maxwell M
 Wells N
​​Blakeway G
 Hellyer K Metcalfe I​  ​Williams N
Bourke X
 ​​Hill C
 ​Mokmool D
 W​right J
​Bugden A and
Bestrin A
 ​Hutchings G and
Dorendahl ​E
 ​Naudi T
 ​Yousif Y​
​Butler W​
 Kabbout M
 ​​​Opiate Overdose
deaths
​Clutton N
 Kessell P
 Pahiva E
​Cruickshank J
 ​​'L'​
 ​​Pearson J
​Doyle B
 Lambert P​
 'RN'​
​Dungay D
 ​​'Levai'
 ​'RP' and 'DJ'

January 2018 - December 2018

Table containing responses to Coronial Recommendations

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'
 Young C
​'FW'
 ​'MA'
 ​​Russell G
 'XX' (Saha)
​Galea D
 Mara A
 Shortland S
 ​
Henderson I
 Martin Q
 Singh K

January 2017 - December 2017 

Table containing responses to Coronial Recommendations

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, Wilson B,
and MacDonald R

January ​2016 - December 2016

Table containing responses to Coronial Recommendations

Inquests mentioned in this table

​Name
2-4 Shaw Street,
Petersham fire
 Day K
 Jung P
 Romeo I
​'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
 Rozs B
 ​Yildrimtekin S

January 2015 - December 2015

Table containing responses to Coronial Recommendations

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 responses to Coronial Recommendations

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 responses to Coronial Recommendations

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 responses to Coronial Recommendations (DOC, 259.0 KB)

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 responses to Coronial Recommendations

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 responses to Coronial Recommendations

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
'DB'
 Jenkinson L
 Parsons M

June 2011 - December 2011

Table containing responses to Coronial Recommendations

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
​Crickitt C
 Gilsenan B
 Locke M
 ​Suppressed #3
​Codner P
 Godden G
 Magro M
 ​Suppressed #4
​Coventry G
 ​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 responses to Coronial Recommendations

Inquests mentioned in this table

​Name
​Ah See N
 Cook M and
Kudrytch J
 Lawler A
 Ren T
Al Mayahi A
 Djordjevic J
 Lopes-Kristen T
 Rose K
Adams T
 Drury J
 McMahon S
 Taylor H and
McGuinness A
Brimble D
 Groat G
 MacKenzie W
 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 responses to Coronial Recommendations

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 responses to Coronial Recommendations

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 responses to Coronial Recommendations

Inquests mentioned in this table

​Name
​Ball J
 ​De Andrade J
 ​LJ Hooker, 
Newtown fire
 ​Suppressed Name
​Berkhout J
 Djordiic S​
 Maina M
 Whitton SC
​Bridger N
 Fontana N
 ​McCarron T
 Worrad G
​Carmichael K
 ​​Hare M
 ​Palmer V​
Chau C​
 Howard Pyrotechnics
fire​
 Pay C​
​Cohn E​
 ​Iredale D​
 ​Shipley A 
 ​
Chung S​
 Jones R
 ​Stace L
 ​
Last updated:

22 Apr 2024