Coronial Recommendations Project Report

Overview

This investigation reviewed the administrative practices of Queensland public sector agencies in assisting coronial inquiries and responding to coronial recommendations. The investigation found that the coronial system did not ensure relevant public sector agencies were sufficiently informed of the inquest or issues to be canvassed at the inquest.

The Ombudsman made observations for the consideration of the State Coroner about ways to improve the procedures followed by coroners in formulating coronial recommendations. A number of possible amendments to the Coroners Act 2003 were also provided together with recommendations to key agencies that had frequent involvement in coronial inquiries.