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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 85 results
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RecommendedDecision of Deputy State Coroner GrahameCORONIAL LAW – interlocutory application – recusal application – application for the Coroner to disqualify herself as the presiding coroner in the inquest – apprehension of bias – Coroner’s adult sister’s public discussion of police
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RecommendedDecision of Deputy State Coroner BaptieCORONIAL LAW – death in police operation – gunshot wound inflicted by police officer – appropriateness of actions of NSW Police Force officers – adequacy of care and treatment provided by NSW Ambulance
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RecommendedDecision of Deputy State Coroner KennedyCORONIAL LAW – police pursuit, death in police operation, decision to initiate police pursuit, relevance of seriousness of offending, conduct of driving, Safe Driving Policy (SDP)
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RecommendedDecision of Deputy State Coroner O'NeilCORONIAL LAW— mental health issues, police operation, siege, negotiations
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RecommendedDecision of Deputy State Coroner GrahameCORONIAL LAW – Death in custody; self-inflicted death; hanging in correctional centre; requests for medical treatment; sleep apnoea; obtaining CPAP machines in custody; adequacy of morning checks
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RecommendedDecision of Deputy State Coroner RyanCORONIAL LAW – death as a result of fall from a height - – the manner of death – was police response appropriate
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RecommendedDecision of Deputy State Coroner LeeCORONIAL LAW – cause and manner of death, tracheostomy management, tracheostomy tube dislodgment, complex airway, bronchoscopy, monitoring of patient, rocuronium administration, blind instrumentation, resuscitation of patient, decompressive finger
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RecommendedDecision of Deputy State Coroner KennedyCORONIAL LAW – death in custody – mandatory inquest – intentional self harm – plastic bags
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RecommendedDecision of Deputy State Coroner RyanCORONIAL LAW – death of a man in lawful custody – requests for medical treatment – was response of the JH Network appropriate – would a more timely response have altered the outcome.
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RecommendedDecision of Deputy State Coroner KennedyCORONIAL LAW – death in custody – mandatory inquest – cell placement – whether medical condition adequately managed
Last updated:
05 Apr 2023
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