Coroner’s Inquest Recommendations and Responses

The Chief Coroner also has the authority to conduct discretionary inquests into deaths of public interest. Inquest juries may issue recommendations to parties that, when implemented, are intended to improve the health and safety of the public and prevent further deaths.

Jury recommendations and subsequent responses from inquests held between the posted dates can be accessed here. The dataset also includes information about the decedent extracted from inquest verdicts for the same period noted above. Please note: As of March 2024, deaths that occur on construction sites are subject to mandatory review, subject to certain exceptions.