Coroners Act 2009

A coroner (whether or not there is a jury) or a jury may make such recommendations as the coroner or jury considers necessary or desirable to make in relation to any matter connected with the death, suspected death, fire or explosion with which an inquest or inquiry is concerned.

Without limiting subsection (1), the following are matters that can be the subject of a recommendation—

public health and safety,

that a matter be investigated or reviewed by a specified person or body.

The record made under section 81 is to include any recommendations made by the coroner or jury. The record must not indicate or in any way suggest that an offence has been committed by any person.

The coroner is to ensure that a copy of a record that includes recommendations made under this section is provided, as soon as is reasonably practicable, to—

the State Coroner (unless the coroner is the State Coroner), and

any person or body to which a recommendation included in the record is directed, and

the Minister, and

any other Minister (if any) that administers legislation, or who is responsible for the person or body, to which a recommendation in the record relates.