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 21 - 30 of 57 results

Inquest into the death of Courtney Topic (494.3 KB,PDF File)

Decision of Deputy State Coroner Ryan

Coronial law, death as a result of a police shooting, high risk mental health related incident, whether responding police breached policies and procedures, whe

Inquest into the death of James BARTON (470.9 KB,PDF File)

Decision of Deputy State Coroner Stone

Coronial law, intentional taking of life, adequacy of mental health assessment, interpretation of S14 and 15 of the Mental Health Act 2007, return of medicatio

Inquest into the death of Ian Fackender (586.4 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - manner of death - death in the course of a police operation - police operation to enforce Community Treatment Order under Mental Health Act 2007

Inquest into the death of Kevin BUGMY (866.6 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW - Death in Custody; Death of ATSI man; use of inhalants; cardiac death; assessing the suitability of inmates for employment in correctional centre

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY (358.3 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW - mother/child homicide/suicide; Borderline Personality Disorder/complex post-traumatic stress disorder; Alprazolam; child protection; adequacy of

Inquest into the death of Paul Lau (540.5 KB,PDF File)

Decision of Acting State Coroner O'Sullivan

Coronial law, Cause and manner of death, TrakCare, Electronic medical records, Anaesthetics, Opioids, Fentanyl, Handover practices

Inquest into the death of Reuben Button (461.7 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Death in custody; Death of ATSI man; ischaemic heart disease; Buvidal; Aboriginal Health Workers at Junee Correctional Centre

Inquest into the death of Trent Nathan Carter (280.9 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Police Operation, motorcycle accident, traffic stop, methylamphetamine effects and contribution

Inquest into the death of David Freeman (2.9 MB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reactio

Inquest into the death of Amelia BLAKE (569.1 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW; Homicide; cause and manner of death

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