Coroners Court New South Wales

Coronial findings and recommendations

To access a finding not listed here, please make application (DOC, 62.0 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 1-10 of 33 results

  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in New South Wales Police Force custody, cause and manner of death, medical assessment of person in custody, charge room and custody management standard operating procedures
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - Dog attack on Collingwood Beach, Vincentia, NSW
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW–unascertained manner of death-cause of death strychnine toxicity-open finding on manner of death
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of a person in custody – was medical treatment appropriate – were cell searches adequate.
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL LAW – Death as a result of fall from a height – manner of death – appropriateness of police response.
  • Recommended
    Decision of Deputy State Coroner O'Neil
    CORONIAL LAW – death in custody, natural causes, HPNFs, record keeping, communication between correctional officers and nursing staff
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - death in custody, cause and manner of death, ischaemic bowel, death during COVID-19 outbreak at Junee Correctional Centre, adequacy of care, adequacy of response to medical emergency
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – diagnosis of mental health condition – psychotic depression / depression with psychotic features – care and treatment provided during admission at Nolan House including adequacy of risk assessments, observations, and treatment
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – mid-gut volvulus and bowel obstruction, ischaemic bowel, unconscious bias, consideration of disability and treatment in hospital, Bathurst Base Hospital, adequacy of care, NETS, provision of care to children in rural NSW
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW – cause and manner of death, exertional heat stroke, exertional heat illness, hyperthermia, seizures, National Rugby League, Heat Policy, Manly Warringah Sea Eagles, Heat Stress Index, Kestrel Heat Stress Tracker, cooling strategies,
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Last updated:

06 May 2024

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