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 151 - 160 of 176 results

Inquest into the death of Heather Winchester (1.8 MB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – elective surgery, informed consent, Jehovah’s witness, documents indicating wishes, documents prepared in USA, unsuitability of documents for NSW

Inquest into the death of Fiona Goodberg (674.5 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – manner of death, intentionally self-inflicted death, mental health diagnosis, mental health assessment, subacute mental health care, postpartum

Inquest into the death of Tammy Michelle Shipley (599.0 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - interlocutory application, jurisdiction, sufficient interest, issues list, interim hearing, scope, recommendations

Inquest into the death of Phillip Boney (304.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – mandatory inquest - death of a First Nations man in custody - was custodial mental health care adequate – were cultural needs adequately met – w

Inquest into the death of Adam Fitzpatrick (1.2 MB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, tracheostomy management, tracheostomy tube dislodgment, complex airway, bronchoscopy, monitoring of patient, rocuroni

Inquest into the death of Roger Frederick Schnelle (408.2 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – diagnosis of mental health condition – psychotic depression / depression with psychotic features – care and treatment provided during admission

Inquest into the death of Ada Holland (550.6 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW - Dog attack on Collingwood Beach, Vincentia, NSW

Inquest into the death of Jacob Carr (340.8 KB,PDF File)

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 ca

Inquest into the death of Simon Cartwright (457.7 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, failure to diagnose, peptic ulcer, natural causes, failure to identify illness, need t

Inquest into the death of William Edmunds (415.6 KB,PDF File)

Decision of Deputy State Coroner Kennedy

Coronial law, cause and manner of death, surgical error, Hartmann’s procedure, ileus, stoma, iatrogenic mechanical bowel obstruction, peritonitis, open disclos

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