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 31 - 40 of 68 results

Inquest into the death of MJ (1.1 MB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW- Dog attack of a five-week-old baby- Examination of the Companion Animals Act 1998 regulatory regime – Recommendations for regulatory changes

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 Naomi Williams (739.6 KB,PDF File)

Decision of Deputy State Coroner Grahame

Coronial law, septicaemia, secondary to Neisseria meningitides infection, nurse directed discharge, implicit racial bias in health care systems, Aboriginal Hea

Inquest into the death of Jet Gallagher (301.7 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW – intentional self-harm – NSW Police and NSW Ambulance powers pursuant to ss 20 and 22 of the Mental Health Act 2007 – extent to which information

Inquest into the disappearance and suspected death of Melissa CADDICK (592.2 KB,PDF File)

Decision of Deputy State Coroner E Ryan

CORONIAL LAW - disappearance of a person - is the person deceased - if so can cause and manner of death be established - was the person suffering a psychiatric

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 DB (847.0 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW - infant death, homicide, non-accidental injuries, FACS, Family and Community Services, DCJ, Department of Communities and Justice, risk of seriou

Inquest into the death of Mohamed Warwar (344.8 KB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – death in custody, natural causes, HPNFs, record keeping, communication between correctional officers and nursing staff

Inquest into the death of William John Torrens (274.2 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – missing person, LANDSAR search, risks for aged care residents with dementia

Inquest into the death of MC (607.5 KB,PDF File)

Decision of Deputy State Coroner Lee

Coronial law, death in custody, Risk Intervention Team, Mental Health Screening Unit, risk assessment, step-down procedures, Management Plan, discharge planning

Last updated:

02 May 2025