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 31-40 of 96 results

Recommended

Inquest into the death of ZA

Decision of Deputy State Coroner Huntsman

CORONIAL LAW, death in custody, fentanyl overdose, search of inmates, x-ray scanners, naxolone (narcan) provision in gaols
Recommended

Inquest into the death of Kerry-Ellen (Nikki) Knight

Decision of Deputy State Coroner Grahame

CORONIAL LAW, death in custody, presence of hanging points in cells, Covid-19 quarantine, access to telephones, mental health and peer support programs, Reception Screening Assessment (RSA), knock ups, Patient Self Referral Form (PSRF), self
Recommended

Inquest into the death of Faithe Baxter

Decision of Deputy State Coroner Stone

CORONIAL LAW - manner of death - whether earlier medical assistance would have changed prospects of survival - whether the available evidence establishes that there was any delay by a person or persons in seeking medical assistance and the extent of
Recommended

Inquest into the death of Trevor SAMUEL

Decision of Deputy State Coroner Ryan

CORONIAL LAW - mandatory inquest - death of a person in custody - whether cause of death can be ascertained - whether the Justice Health and Forensic Mental Health Network provided adequate care and treatment
Recommended

Inquest into the death of S B

Decision of Deputy State Coroner Lee

CORONIAL LAW - self-inflicted death of involuntary patient , Kaoriki House, clinical documentation, neuropsychiatric assessment, forensic assessment, risk assessment, observation levels, Mental Health Act 2007, Mental Health and Cognitive Impairment
Recommended

Inquest into the death of M G

Decision of Deputy State Coroner Kennedy

CORONIAL LAW - Manner of Death - Suicide Intervention - Police Operation - Appropriateness and adequacy of police response - Intentional taking of life
Recommended

Inquest into the disappearance of CD

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Missing person – manner of death – Police Investigation – Appropriateness and adequacy of police response – Appropriateness of legislative interpretation of legislation relating to triangulation – construction of s 287,
Recommended

Inquest into the death of Ian Fackender

Decision of State Coroner O'Sullivan

CORONIAL LAW - manner of death - death in the course of a police operation - police operation to enforce Community Treatment Order under Mental Health Act 2007 - uninvited entry into premises to enforce Community Treatment Order - planning and risk
Recommended

Inquest into the death of Sophia Bolshesolsky

Decision of DSC Forbes

CORONIAL LAW - Pedestrian death - should the NSW Police Crash Investigation Unit have been called to investigate the accident - safety for pedestrians in John Street, Lidcombe
Recommended

Inquest into the death of Gavin Ellis

Decision of Deputy State Coroner Forbes

CORONIAL LAW - self-inflicted death in custody - mandatory inquest - adequacy of mental health care - Care Pathways Model for Custodial Mental Health - Renewed Model of Care and Implementation Plan - Waitlists for psychiatric review - Risk

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Coronial findings and recommendations

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