Coronial findings and recommendations

CORONIAL LAW – mandatory inquest – death of a person in lawful custody – self-inflicted intentional death

CORONIAL LAW – mandatory inquest – death of a person by homicide – coercive control – was response of NSW Police Force to reports of domestic and family violence adequate – is risk assessment tool used by NSW Police Force adequate?

CORONIAL LAW – Cause and manner of death – death in custody

CORONIAL LAW – intentional self-harm – NSW Police and NSW Ambulance powers pursuant to ss 20 and 22 of the Mental Health Act 2007 – extent to which information from friends and family should be taken into account when assessing risk of

CORONIAL LAW - death of a twenty-month-old girl from multiple injuries that were inflicted by a known person - two presentations to hospital with suspicious injuries in the two weeks prior to her death - adequacy of systemic response to those

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, failure to diagnose, peptic ulcer, natural causes, failure to identify illness, need to deliver treatment, involuntary detained inmate, waitlist for appropriate mental health

CORONIAL LAW – Missing Person, Mental Health

CORONIAL LAW – Death as a result of police operation –– First Nations death – restraint of person in the prone position – was the response of police and ambulance officers appropriate, and consistent with policy and training –

CORONIAL LAW – death in a police operation; police shooting; self-inflicted death; actions to provoke police to shoot; PACER program; police response to persons experiencing mental health crises

CORONIAL LAW - Missing person, search, and whether missing person is now deceased.