Coronial findings and recommendations

CORONIAL LAW – circumstances of accident and death – survivability – response by NSWPF to report of person missing – search and rescue – search urgency assessment forms – regulatory and advisory regime relating to backcountry skiing in

CORONIAL LAW- request by deceased for police to attend his house with an intention of provoking police to shoot him and end his life by pointing a rifle at them - police response to that request - mental health care - mental health care training for

CORONIAL LAW – death in custody, mental health, mentally ill person, transfer from custody to receive care, section 24 Crimes (Administration of Sentences) Act 1999, Section 86 Mental Health and Cognitive Impairment Forensic Provisions Act 2020,

CORONIAL LAW – First Nations death in custody – section 23 mandatory inquest – prisoner attempting escape during medical escort – shot by firearm discharged by correctional officer – findings as to manner and cause of death – whether

CORONIAL LAW failure of diagnosis, perforated duodenal ulcer, insufficient medical investigations, necessity of identification of First Nations status when providing medical treatment, culturally appropriate treatment, natural causes, Dubbo Base

CORONIAL LAW – diagnosis of mental health condition – care and treatment provided, Community Corrections assessment prior to release on parole, service provision for parolee in the community, compliance with pre-release requirements, death in

CORONIAL LAW - cause and manner of death - cardiac arrhythmia - Torsades de Pointes - medical prescription of methadone (Physeptone tablets) - appropriateness of dosage, induction rate and medical supervision of methadone prescription - application

CORONIAL LAW – mandatory inquest - death of a First Nations man in custody - was custodial mental health care adequate – were cultural needs adequately met – was the transfer of health care information effective – have reasonable efforts

CORONIAL LAW – missing person in a remote area – death due to methamphetamine and buprenorphine use – heat and dehydration as contributing factors – police land search and rescue (LANDSAR operation) – NSWPF training with regard to working

CORONIAL LAW - missing person, referral to NSW Police Unsolved Homicide Team