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 35 results

  • Recommended
    Decision of Deputy State Coroner Ryan
    Coronial Law - mandatory inquest, death of a person in a police operation, cause of death, appropriateness of response of NSW Police Force officers and of psychologist case worker, availability of NSW Real Time Prescription Monitoring Scheme
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody, cause and manner of death
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - cause and manner of death - sudden unexpected cardiac death - Army Recruit Course - Australian Defence Force - Army Recruit Training Centre - Kapooka - Exercise Challenge - Tunnel Obstacle - risk assessment - emergency
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody, cause and manner of death
  • Recommended
    Decision of Deputy State Coroner Stone
    Coronial Law - cause of death, cardiac arrythmia during restraint, deceased in care of Department of Communities and Justice, intellectual disability, case management responsibility by Challenge, role each played in overall care, rising
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - cause and manner of death - homicide - unascertained cause of death
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW - suicide by a police officer - death a result of police operations - adequacy of risk assessment
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW - malignant ventricular arrhythmia - heart disease - mandatory inquest - positional asphyxia - use of a taser - use of force - supervision - NSW Police Force - Royal Prince Alfred Hospital - Corrective Service NSW - police
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - death following mental health treatment discharge; whether intention existed to end life; 'malingering"; homelessness as a stressor in mental health; communication when transitioning care; "complex case"; drug and alcohol
  • Recommended
    Decision of Coroner Soars
    Coronial Law - brown snakebite envenoming, manner of death, care and treatment
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Last updated:

13 Jan 2021

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