The report recommends that Ambulance Tasmania outline what KPIs are measured and provide targets or benchmarks to define what is good or poor performance.

The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions.

The report recommends that Ambulance Tasmania collects data to allow regular and meaningful comparison of clinical outcomes at the regional level, to better allocate resources and to rapidly identify problems.

That Tasmania Police establishes a section within its structure with responsibility for developing and maintaining contemporary expertise in emergency management, progressing innovation, assisting organisational change initiatives and supporting its responsibilities in state emergency management arrangements.

That Tasmania Police conducts a review to ensure emergency management is treated as a priority and a core function throughout the organisation, including the development of contemporary capabilities, and is supported by an appropriate culture.

That Tasmania Police develops and implements a program for examining emergency management arrangements and facilities in Australia.

That the recommendations contained in the Police Operational Debrief Report of 22 October 2007 to 7 November 2007, submitted to the Coroner, be further considered by the Tasmania Police for adoption where considered appropriate by Tasmania Police.

Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly.