Last updated 20 January 2022

The coroner is able to comment and make recommendations on anything connected with an inquest that relates to public health or safety, the administration of justice or preventing future deaths in similar circumstances (s 46(1) Coroners Act 2003 (Qld) (Coroners Act)). A written copy of these comments must be given to the relevant family member and any person with a sufficient interest who attended the inquest (s 46(2) Coroners Act). The coroner must not include any statements relating to the civil or criminal liability of any person in their findings or comments but may refer matters to another agency for further investigation (s 46(3) Coroners Act).

Recommendations may be specifically directed at agencies in order to prevent deaths from similar circumstances in the future (s 3(d) Coroners Act). Recommendations may have a broad rather than direct connection to the death being investigated (see Doomadgee v Clements [2005] QSC 357, 360; Thales Australia Limited v The Coroners Court & Ors [2011] VSC 133). However, any recommendation must relate to public health or safety, the administration of justice or death prevention (s 46(1) Coroners Act).

Before making a recommendation, the coroner will usually seek input from affected agencies to ensure that the proposed recommendation can be practically implemented. Where practicable, this will occur prior to the inquest to ensure that the parties have sufficient time to consider the circumstances and make suggestions for the coroner’s recommendations.

While the Coroners Act does not mandate a government response to coronial recommendations, there is an administrative arrangement that requires relevant government agencies to publicly report on their response. These responses are published on the Department of Justice and Attorney-General website.

Case Study: Dreamworld

On 25 October 2016, the Thunder River Rapids Ride at Dreamworld malfunctioned, causing two rafts to collide. Although the ride operators and emergency services immediately responded to the incident, the four riders died at the scene (see Inquest into the deaths of Kate Louise Goodchild, Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (2020) 2016/4486, 2016/4485, 2016/4480, 2016/4482).

The inquest highlighted serious failures to review and update safety procedures at Dreamworld. The coroner also identified a lack of clarity in the standards governing theme park rides, and recommended changes to Queensland’s regulatory framework around inspecting and licensing major amusement park rides.

The government responded by introducing comprehensive new safety requirements under the Work Health and Safety Regulation 2011 (Qld). The government is also considering a Code of Practice for amusement rides in order to update standards.