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 27 results

  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW – cause and manner of death, cardiac arrythmia, QT prolongation, hypothyroidism, compliance with thyroxine medication, endocrine management, thyroid function test, endorsement of pathology results, multidisciplinary team meetings,
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - cross- agency responses to domestic violence
  • Recommended
    Decision of Deputy State Coroner O’Neil
    CORONIAL LAW – missing person –overboard from boat –search –not possible to survive –
  • Recommended
    Decision of Deputy State Coroner Pearce
    CORONIAL LAW – death as a result of police operation – First Nations man – appropriateness of police response
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW – death as a result of fall from height, NSW Police operation, apprehended domestic violence order, appropriateness of NSW Police response
  • 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 Grahame
    CORONIAL LAW – intentionally self-inflicted death; death of a young person; family violence and neglect – family known to the NSW Department of Communities and Justice; educational neglect; systemic response to homelessness, abuse and neglect of
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Last updated:

24 Mar 2025

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