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New report provides insight into coroners’ recommendations

Wednesday 31 March 2021

Coronial recommendations aimed at saving Victorian lives are the subject of a new quarterly report published today by the Coroners Court of Victoria.

The first edition of the Coroners Court of Victoria Recommendations Report includes all coronial recommendations from 1 January to 31 December 2020 – providing an insight into important health and safety issues identified by coroners and the actions being taken to address them. 

The Court plays a unique and vital role in protecting the Victorian community. Each year, the Court independently investigates approximately 7000 cases of sudden or unexpected deaths, deaths of people in care or custody, and fires – to reveal when, where, how and why the incidents occurred.

Where a prevention opportunity is found, coroners make recommendations and in doing so drive reforms that strengthen public health and safety responses.
Any public statutory authority or entity to whom a recommendation is directed must respond, in writing, within three months stating what action, if any, has or will be taken. The Court publishes all responses to recommendations on

From 1 January to 31 December 2020, coroners made 176 recommendations across 77 findings.
Following these recommendations, the Court received:

  • 131 responses stating the recommendation was accepted in full
  • 12 responses stating the recommendation was accepted in part or an alternative was proposed
  • 21 response stating the recommendation remains under consideration
  • 1 response where the recommendation was not accepted

In addition to these:

  • 13 responses are still being prepared within the required three-month time frame (awaiting a response)
  • 14 responses have not been received within the required time frame (overdue)

Please note, a coroner may direct a recommendation to multiple parties. As such, the number of responses required may exceed the number of recommendations made.
All findings and responses can be accessed via the hyperlinks in each case entry of the report.  

Quotes from State Coroner Judge John Cain

“The Court’s work contributes significantly to the safety of the Victorian community. This report illustrates the breadth and diversity of this work.” 

“Through this report we can provide the community with information on the issues that affect their health and wellbeing – an informed community is an empowered community.”

“The publication of this report quarterly will ensure the ongoing transparency of responses from entities to coroners’ recommendations.”

A copy of the report can be accessed at:

Media contact:
Claudia Hodgens 
Strategic Communications Manager
T: 0407 403 371