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 85 results

  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL 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
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL 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
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – police pursuit, death in police operation, decision to initiate police pursuit, relevance of seriousness of offending, conduct of driving, Safe Driving Policy (SDP)
  • Recommended
    Decision of Deputy State Coroner O'Neil
    CORONIAL LAW— mental health issues, police operation, siege, negotiations
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL 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
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – death as a result of fall from a height - – the manner of death – was police response appropriate
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL 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
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – death in custody – mandatory inquest – intentional self harm – plastic bags
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL 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.
  • Recommended
    Decision of Deputy State Coroner Kennedy
    CORONIAL LAW – death in custody – mandatory inquest – cell placement – whether medical condition adequately managed
Page 1 of 9
Last updated:

05 Apr 2023

Was this content useful?
We will use your rating to help improve the site.
Please don't include personal or financial information here
Please don't include personal or financial information here
Top Return to top of page Top