Coronial findings 

To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 1-10 of 82 results

  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death of inmate at Long Bay Hospital – natural causes death – care and treatment appropriate.
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – death in custody, 911 tool, corrective officer training in response to hanging,
  • Recommended
    Decision of Deputy State Coroner LEE
    CORONIAL LAW – cause and manner of death, ruptured aneurysm, subarachnoid haemorrhage, undiagnosed hypertension, administration of aspirin, Adult Nurse Initiated Medication Protocols
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW-death in custody, cause and manner of death-methadone toxicity-Justice Health-opioid substitution therapy
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – missing person, triangulation, adequacy of search, compliance with NSW Police Force Standard Operating Procedures – Missing Persons, Unidentified Bodies & Human Remains, communication with family and friends in missing
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – methylamphetamine, drug addiction, emergency department presentation of an ice affected patient seeking help, result of physical restraint on an individual on ice
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – unexpected hospital death; Sugammadex; anaphylaxis; appendicectomy; acute appendicitis; Open Disclosure policy
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW-death in custody, cause and manner of death, intentionally self-inflicted
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW, provision of respite care, carer ratios, carer training, transport related death
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW, accidental death, respite care, voluntary out of home care (VOOHC), unsafe environment in VOOHC, Civic Disability Services
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Last updated:

12 Nov 2021

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