Coronial recommendations

Coroners—usually magistrates in your community—investigate deaths that are ‘unnatural’, such as:

  • accidents, suicides or homicides
  • deaths that have occurred in prison or in care
  • deaths with unknown causes.

A coroner will investigate the circumstances surrounding the death, determine the cause and identify any public health or safety issues that caused the death.


An inquest is a public hearing before the coroner where witnesses are called to give evidence.

They usually held when the coroner decides based on police and medical reports that a formal hearing is needed to obtain and consider additional evidence.

When an inquest is over, the coroner may comment on anything connected with the death that relates to:

  • public health or safety
  • the administration of justice
  • ways to prevent deaths from happening in similar circumstances in the future.

Comments and recommendations can be, and often are, directed to us.

We consider each of the recommendations and comments Queensland coroners direct to us at inquests. We then respond to every recommendation directed to us and detail if (and how) we plan to implement them.

Responses to past recommendations

Our responses to recommendations handed down after 2012 are posted next to the findings of the inquests.

We aim to publish a response to recommendations within 6 months of the recommendations being made and to provide implementation updates twice a year until the recommendation is implemented (or a decision is made not to support the recommendation).

While nothing will compensate for the loss of a loved one, it is hoped that the families and friends will receive some comfort from knowing that the recommendations aimed at preventing similar tragic deaths have been considered by us and in most cases implemented.

Recommendations 2012 or earlier

For 5 years before this, we produced annual reports detailing our responses to coroners’ recommendations.

Read our responses to coronial recommendations for 2008 to 2012.

Specific enquiries

If you have any questions about the implementation of specific recommendations, please contact the responsible department named in the response.