Coroners Court New South Wales

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 1-10 of 75 results

  • Recommended
    Decision of Deputy State Coroner Hosking
    CORONIAL LAW - Can cause and manner of death be established? Mental health diagnosis and treatment; medical response to suicide risk
  • Recommended
    Decision of Deputy State Coroner Hosking
    CORONIAL LAW - identification of a missing person, NSW police application of policies and procedures in relation to missing persons and fingerprinting
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – mandatory inquest – death of a person in lawful custody – self-inflicted intentional death
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – mandatory inquest – death of a person by homicide – coercive control – was response of NSW Police Force to reports of domestic and family violence adequate – is risk assessment tool used by NSW Police Force adequate?
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW – Cause and manner of death – death in custody
  • Recommended
    Decision of Deputy State Coroner Hosking
    CORONIAL LAW – intentional self-harm – NSW Police and NSW Ambulance powers pursuant to ss 20 and 22 of the Mental Health Act 2007 – extent to which information from friends and family should be taken into account when assessing risk of
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - death of a twenty-month-old girl from multiple injuries that were inflicted by a known person - two presentations to hospital with suspicious injuries in the two weeks prior to her death - adequacy of systemic response to those
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – Correctional inmate, failure to observe signs of illness, failure to diagnose, peptic ulcer, natural causes, failure to identify illness, need to deliver treatment, involuntary detained inmate, waitlist for appropriate mental health
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW – Missing Person, Mental Health
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – Death as a result of police operation –– First Nations death – restraint of person in the prone position – was the response of police and ambulance officers appropriate, and consistent with policy and training –
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Last updated:

23 Oct 2024

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