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 58 results

  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - self-inflicted death of involuntary patient , Kaoriki House, clinical documentation, neuropsychiatric assessment, forensic assessment, risk assessment, observation levels, Mental Health Act 2007, Mental Health and Cognitive
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW - Manner of Death - Suicide Intervention - Police Operation - Appropriateness and adequacy of police response - Intentional taking of life
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW - manner of death - death in the course of a police operation - police operation to enforce Community Treatment Order under Mental Health Act 2007 - uninvited entry into premises to enforce Community Treatment Order - planning
  • Recommended
    Decision of DSC Forbes
    CORONIAL LAW - Pedestrian death - should the NSW Police Crash Investigation Unit have been called to investigate the accident - safety for pedestrians in John Street, Lidcombe
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - self-inflicted death in custody - mandatory inquest - adequacy of mental health care - Care Pathways Model for Custodial Mental Health - Renewed Model of Care and Implementation Plan - Waitlists for psychiatric review - Risk
  • Recommended
    Decision of Deputy State Coroner Huntsman
    CORONIAL LAW, young First Nations man, death in residential drug rehabilitation facility, forensic patient order, cultural safety in provision of health services
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW, cause and manner of death, methadone prescription and dispensing, takeaway dose, opioid treatment program, safety assessment and safety planning for problematic alcohol and drug use
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW, natural causes death in custody, care and treatment of quadriplegic inmate in custody
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL LAW, cause and manner of death, care and treatment at Wagga Wagga Base hospital, pre-operative screening processes in the context of co-morbidities
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW, fatal stabbing, attacker not guilty by reason of mental illness, adequacy of mental health care in community
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Last updated:

12 Nov 2021

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