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.

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Showing results 1 - 10 of 1009 results

Inquest into the death of Daniel Leehy (263.1 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – death in custody, cause and manner of death

Inquest into the death of Robert Muir (290.2 KB,PDF File)

Decision of Deputy State Coroner Devine

CORONIAL LAW – Mandatory inquest – Audley Cave - unascertained manner and cause of death

Inquest into the death of Valmai Jane Birch (178.5 KB,PDF File)

Decision of Deputy State Coroner Devine

CORONIAL LAW – homicide – mandatory inquest

Inquest into the death of Frank Valentine (185.9 KB,PDF File)

Decision of Deputy State Coroner Devine

CORONIAL LAW – Mandatory inquest pursuant to s 23 (1)(d)(ii) of the Coroners Act 2009 (NSW) – natural causes – no care or treatment concerns.

Inquest into the disappearance and suspected death of Habtom Ghilagaber (435.0 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – whether missing person now deceased, date and place of death, cause and manner of death, adequacy and timeliness of missing person investigation

Inquest into the death of Michael Black (1.4 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – death in custody – Parklea Correctional Centre – stab wound to the chest – use of gaol-made weapon – 18 inmates in holding cell – failure to sea

Inquest into the death of Ashley Paull (2.7 MB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW collision with truck whilst walking along highway - mental health in custody - release from police custody after detention for secondary drug test

Inquest into the death of Wilfred Whippy Williams (533.9 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Discretionary inquest – death of First Nations man following emergency presentation to Cowra District Hospital – deceased did not wait during tr

Inquest into the death of Margaret Mariani (455.5 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – complications of cholecystectomy surgery – grossly inadequate care and treatment provided at Forster Private Hospital – inadequate monitoring an

Inquest into the death of Allyson Bailey (455.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

Coronial inquest, unanticipated death in hospital , interaction between provision of physical and mental health treatment, impact of Covid-19 on hospital care.

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