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 161 - 170 of 176 results

Inquest into the death of Harmony (1.7 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – intentionally self-inflicted death; death of a young person; family violence and neglect – family known to the NSW Department of Communities and

Inquest into the death of Maureen Smith (1.3 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Glen Innes District Hospital, Armidale Rural Referral Hospital, referral of medical practitioner to the Medical Council of NSW, signs of clinica

Inquest into the death of Andrew Seton (3.1 MB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW – circumstances of accident and death – survivability – response by NSWPF to report of person missing – search and rescue – search urgency assessm

Inquest into the death of Kevin Edwards (552.6 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW – death as a result of a police operation – 23(1)(c) and 27(1)(b) of the Coroners Act 2009 – diagnosis of drug-induced psychosis – diagnosis of su

Inquest into the death of DB, JD, DC, RG, AH, AB (577.6 KB,PDF File)

Decision of Deputy State Coroner Grahame

Coronial law, opiate overdose, opioid overdose, fentanyl, naloxone, multi-drug toxicity, methadone, recommendations to prevent opioid or opiate deaths, oxycodo

Inquest into the death of Kerry-Ellen (Nikki) Knight (424.5 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW, death in custody, presence of hanging points in cells, Covid-19 quarantine, access to telephones, mental health and peer support programs, Recept

Inquest into the death of Baylen Pendergast (550.2 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW - suspicious death of a child, cause and nature of paediatric head injuries, whether head injuries were non-accidental, care provided at Tamworth

Inquest into the death of Ms K (464.4 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW - mandatory inquest, death of a person by homicide, coercive control, was response of NSW Police Force to reports of domestic and family violence

Inquest into the death of JY (475.1 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - acute psychotic episode, schizophrenia, was mental health care appropriate, recommendations to expand REACH program in public mental health sett

Inquest into the death of Gordon Copeland (419.4 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - death by drowning, First Nations death, Gomeroi man, police search

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