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 301 - 310 of 560 results

Inquest into the death of L (392.1 KB,PDF File)

Decision of Deputy State Coroner Ryan

Coronial law, mandatory inquest, death of a person in custody, Parklea Correctional Centre, what was cause of death, was mental health care provided by the GEO

Inquest into the death of Savvas Epsimos (335.6 KB,PDF File)

Decision of Deputy State Coroner O'Sullivan

Coronial law, Cause and manner of death, Aged care facility, Falling out of bed

Inquest into the death of James Leslie STOCKS (623.3 KB,PDF File)

Decision of Deputy State Coroner Grahame

Coronial law, manner of death

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 death of Dr Beta Vandeville (643.6 KB,PDF File)

Decision of Deputy State Coroner Lee

Coronial law, propofol, fentanyl, midazolam, restricted substances, anaesthetist, Royal Australian College of Obstetricians and Gynaecologists

Inquest into the death of RP and DJ (990.3 KB,PDF File)

Decision of Deputy State Coroner Grahame

Coronial law, death in custody, Health Problem Notification Form ('HPNF'), treatment of acute mental illness in custody, and mental health.

Inquest into the death of Alen Imbrisak (347.5 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW – death in custody – manner and cause of death during COVID-19 outbreak at Junee Correctional Centre – adequacy of care

Inquest into the death of Paul Lambert (477.7 KB,PDF File)

Decision of Acting State Coroner O'Sullivan

Coronial law, cause and manner of death, police shooting, mental health, history of intimate partner violence and stalking, suggestion of consideration of non-

Inquest into the death of MA (729.6 KB,PDF File)

Decision of Acting State Coroner O'Sullivan

Coronial law, suicide risk assessments and risk levels, nursing engagement and observation levels in Mental Health Units.

Inquest into the deaths of Nicholas KARAYIANNIS and Tien TRAN (136.0 KB,PDF File)

Decision of Deputy State Coroner Dillon

CORONERS, cause and manner of death, deaths in custody, Homicide/suicide of cellmates, Whether mental health assessment reasonable, Whether prisoners safe at n

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