Coroners Court New South Wales

Coronial findings and recommendations

To access a finding not listed here, please make an application (PDF, 112.1 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 1-10 of 20 results

  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information exchange between NSW Police Force and NSW Ambulance.
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of person in immigration detention – self-inflicted intentional death – was mental health care adequate – were there adequate communications regarding repatriation to home country – were there adequate measures to
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – appropriateness of care and treatment provided to persons in immigration detention by
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of a person in immigration detention – were mental health care services adequate – was monitoring by detention staff adequate - is there a need for improved system for information sharing – are measures to reduce the
  • Recommended
    Decision of Deputy State Coroner Hosking
    CORONIAL LAW – Death as a result of police operations; NSW police application of policies and procedures in relation to motor vehicle pursuits.
  • Recommended
    Decision of Deputy State Coroner O'Neil
    CORONIAL LAW – elective surgery, informed consent, Jehovah’s witness, documents indicating wishes, documents prepared in USA, unsuitability of documents for NSW
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - Dog attack of a two-year-old boy - Examination of the Companion Animals Act 1998 regulatory regime - Recommendations for regulatory changes
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death in custody – care and treatment – requirements and frequency of physical observations – policies, procedures, and training applicable to supervision and management of inmates in the Acute Care Management Unit
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reaction, Tenterfield Hospital, absence of medical officer, lack of nurse accreditation in
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – Correctional inmate, failure to observe signs of illness, natural causes, need to deliver treatment, 24 hour surveillance cell, RIT, mental illness, schizophrenia, psychogenic polydipsia, hyponatremia.
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Last updated:

26 Feb 2025

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