Every year, the Coroners Court of Victoria hands down findings that include formal recommendations aimed at preventing future deaths — covering everything from hospital protocols to workplace safety to policing practices. But a recommendation is not a law, and our newsroom has spent months examining what actually happens once a coroner puts one on the public record.
The short answer: some recommendations reshape entire systems. Others are accepted in writing and then quietly shelved. Understanding the difference requires understanding how the process is designed to work — and where it relies on goodwill rather than compulsion.
What a coronial recommendation actually is #
Under the Coroners Act 2008 (Vic), a coroner investigating a reportable death may make recommendations to “any Minister, public statutory authority or entity” the coroner considers appropriate, connected to the prevention of similar deaths. These are formally known as “comments” or recommendations attached to a finding, and they sit outside the coroner’s core legal task of establishing the identity of the deceased, and the cause and circumstances of death.
Crucially, a coroner has no power to compel an organisation to adopt a recommendation. Coroners can identify a risk and propose a fix, but implementation is left entirely to the body the recommendation is directed at — a hospital network, a government department, Victoria Police, WorkSafe, or a private operator. This is a deliberate design feature of coronial law across Australia, reflecting the view that coroners should investigate and advise, not govern.
The response obligation — and its limits #
Victoria does have a formal response mechanism. Section 72(3) of the Coroners Act requires that where a coroner makes a recommendation, the relevant organisation “must” respond to the coroner in writing within a set period, usually three months, setting out what action — if any — it intends to take. That response becomes part of the public coronial record and can be published by the court.
In practice, this means every recommendation should eventually generate a documented reply. But the obligation is to respond, not to comply. An organisation can lawfully write back to the court and say a recommendation will not be adopted, provided it explains why. There is no statutory penalty for rejecting a coronial recommendation outright, and no mechanism compelling a change of position if the first response is negative.
This is the crux of the “implementation gap” that court-watchers, including our own newsroom, regularly track: acknowledgement is mandatory, action is not.
Who monitors what happens next #
Once a response is filed, formal monitoring becomes patchier. The Coroners Court itself does not have an ongoing compliance unit that chases up agencies years after a finding is published — its statutory role effectively ends once the finding and any response are on the record. Continued oversight tends to fall to a combination of:
- Parliamentary committees, which can question ministers about implementation during estimates hearings or inquiries
- The Victorian Auditor-General’s Office, which has previously audited whether specific coronial recommendations in areas such as workplace safety and family violence were actually actioned
- Advocacy and peak bodies — including unions, victim-support organisations and clinical colleges — that publicly track whether recommendations affecting their sector have been adopted
- Journalists and researchers, who periodically revisit high-profile findings to test whether promised reforms materialised
None of these mechanisms is guaranteed or systematic. There is no single published register that tracks every Victorian coronial recommendation against its implementation status in real time, which is one reason the same systemic issues — a particular type of workplace hazard, a gap in information-sharing between services — can resurface in later findings.
Where the system has driven real change #
Despite those gaps, Victorian coronial findings have been credited with genuine reform over time. Recommendations arising from inquests into industrial incidents have previously informed changes to WorkSafe guidance and industry codes of practice. Findings touching on information-sharing between services have fed into broader multi-agency risk-assessment reforms in the family violence sector, developed alongside the Royal Commission into Family Violence rather than in isolation.
Coronial findings have also prompted changes to protocols in emergency departments, ambulance dispatch and mental health service handovers, where hospital networks and Ambulance Victoria have publicly confirmed adopting recommended procedural changes following specific findings. In these cases, the coroner’s recommendation appears to have acted as a catalyst — providing an independent, evidence-based trigger for a change that internal reviews alone had not produced.
The common thread in cases where recommendations stick is external pressure beyond the coronial finding itself: media attention, sustained advocacy from affected families or professional bodies, or alignment with a broader government reform agenda already underway. Recommendations that land without that surrounding pressure are more vulnerable to being accepted “in principle” and then not meaningfully progressed.
Why some recommendations stall #
Agencies asked to respond to coronial recommendations frequently cite resourcing constraints, competing legislative priorities, or the need for further consultation before committing to a specific fix. Some recommendations require budget allocation that sits with a different arm of government to the one that received the finding, complicating accountability — a recommendation directed at a hospital network, for instance, may in practice require state budget funding that only the Health Minister can authorise.
Other recommendations are contested on technical or legal grounds; an agency may accept the underlying concern but argue the coroner’s specific proposed fix is not workable, and propose an alternative it says addresses the same risk. Under the Act, that is a legitimate response, though it can mean the public record shows a recommendation as “responded to” without the substance of the coroner’s concern necessarily being resolved.
What families and the public can do #
Families involved in an inquest, and members of the public, can request copies of findings and any subsequent responses through the Coroners Court’s public findings database, which publishes many — though not all — findings and associated recommendations. Where a response has not been published or appears overdue, inquiries can be directed to the Coroners Court registry.
Beyond the court itself, state parliamentary committees and the Victorian Auditor-General’s Office can be petitioned or lobbied to examine implementation of specific recommendations, particularly where multiple findings across different cases have identified the same unresolved systemic risk. Advocacy groups working in relevant sectors — occupational health and safety, family violence, mental health — often maintain their own tracking of recommendations relevant to their area and can provide independent context on whether a stated response has translated into practice.
Our newsroom will continue to report on coronial findings and, where relevant, on whether recommendations arising from them have subsequently been implemented, consistent with the public interest in transparent government and institutional accountability.
Support services #
Readers affected by issues raised in this article, including bereavement following a reportable death, can contact Lifeline on 13 11 14, Beyond Blue on 1300 22 4636, or 13YARN on 13 92 76 for Aboriginal and Torres Strait Islander support. Support related to family violence is available through 1800RESPECT on 1800 737 732 or Safe Steps on 1800 015 188. Anyone with information for police can contact Crime Stoppers on 1800 333 000.
