Coroners Court New South Wales

Coronial findings and recommendations

To access a finding not listed here, please make an application (PDF, 112.1 KB) to the Court. In some inquests, recommendations are made to Ministers and Government and non-government agencies. For a full list of recent recommendations and responses, please go to this site.

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Showing results 1 - 10 of 1144 results

Inquest into the death of Emily Warn (739.0 KB ,PDF File)

Decision of Judge Carmel Forbes, Deputy State Coroner

CORONIAL LAW – Boat capsize over the Penrith Weir-Subsequent drowning - Missing safety buoys barrier at the weir -Issues with the inspection and replacement of

Inquest into death of Melissa Jane Du Pont (480.3 KB ,PDF File)

Decision of Judge David O'Neil, Deputy State Coroner

CORONIAL LAW – unascertained matter and cause of death

Inquest into the death of AT (282.7 KB ,PDF File)

Decision of Judge Rebecca Hosking, Deputy State Coroner

S 23(1)(c) Coroners Act 2009 (NSW) Death in police operation, police response to mental health episode

Inquest into the death of Toi Dix Hohaia (216.2 KB ,PDF File)

Decision of Judge Rebecca Hosking, Deputy State Coroner

S 23(1)(a) Coroners Act 2009 (NSW), natural death in custody

Inquest into the death of Mr Jake Andrew Carter (504.8 KB ,PDF File)

Decision of Judge Carmel Forbes, Deputy State Coroner

CORONIAL LAW – mandatory inquest – death in custody – was the cause of death asthma or arrythmia – was the medical care and treatment appropriate

Inquest into the death of Hsiu Kuo (487.7 KB ,PDF File)

Decision of Judge Derek Lee, Deputy State Coroner

CORONIAL LAW – date and place of death, cause and manner of death, missing person with dementia, coordinated land search, LandSAR Coordinator, CCTV canvassing,

Inquest into the suspected death of missing person Adshaiyan Arunasalam (240.3 KB ,PDF File)

Decision of Judge Derek Lee, Deputy State Coroner

CORONIAL LAW – whether missing person now deceased, date and place of death, cause and manner of death, Little Bay Beach

Inquest into the death of Kate Manley (349.3 KB ,PDF File)

Decision of Judge Rebecca Hosking, Deputy State Coroner

Cause of death; pulmonary embolism; assessment of risk of venous thromboembolism in a psychiatric ward; impact of the delineation of treatment for physical and

Inquest into the death of Marina Morel (477.1 KB ,PDF File)

Decision of Judge Derek Lee, Deputy State Coroner

CORONIAL LAW – manner of death, injury in racehorses, stress fracture, ligamentous injury, ruptured oblique sesamoidean ligament, injury management prior to tr

Inquest into the death of Helen Frances Honey (671.7 KB ,PDF File)

Decision of Judge Stuart Devine, Deputy State Coroner

CORONIAL LAW - involuntary patient - Mental Health Older Persons Unit - abdominal aortic aneurysm - adequacy of Rapid Response Team and Emergency Department re

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