Coronial findings and recommendations

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,

CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - cross- agency responses to domestic violence

CORONIAL LAW – missing person –overboard from boat –search –not possible to survive –

CORONIAL LAW – death as a result of police operation – First Nations man – appropriateness of police response

CORONIAL LAW – death as a result of fall from height, NSW Police operation, apprehended domestic violence order, appropriateness of NSW Police response

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.

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

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

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

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