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 341 - 350 of 562 results

Inquest into the death of SF (357.3 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – death in custody – self-inflicted injury – adequacy of CSNSW’s monitoring – availability of hanging points – assessment and determination of app

Inquest into the death of Nick NEWMAN (372.8 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW - death of a person in a police operation - was proper risk assessment performed - was there appropriate communication between the involved office

Inquest into the death of Ivan Goolagong (1.2 MB,PDF File)

Decision of Deputy State Coroner Truscott

Coronial law, cause and manner of death, First Nations Patients, palliative care, death in corrections custody, Justice Health, care and treatment

Inquest into the death of SB (256.0 KB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW— mental health issues, police operation, siege, negotiations

Inquest into the death of David BROWNE (201.4 KB,PDF File)

Decision of Deputy State Coroner O'Sullivan

Coronial law, cause and manner of death, combat sports, boxing

Inquest into the death of Roy Roberts (518.1 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, diagnosis of primary epilepsy, seizure-like episode, methadone toxicity, opioid substitution therapy, unprescribed dr

Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS (380.3 KB,PDF File)

Decision of Deputy State Coroner Barry

Coronial law, cause and manner of death, ingestion of methanol, distilling and sale of spirits, organising pneumonia, alcoholic liver disease

Inquest into the death of Margaret Elizabeth HILLS (102.7 KB,PDF File)

Decision of Deputy State Coroner MacMahon

Coronial law, person missing presumed deceased, person charged with indictable offence, suspended inquest, resumed inquest, standard of proof, self-inflicted d

Inquest into the death of Alan BUGDEN and Amaru BESTRIN (540.6 KB,PDF File)

Decision of Deputy State Coroner, Magistrate Harriet Grahame

CORONIAL LAW – death in hospital toilet, toilet cleaning and inspection systems, toilet alarm technologies, medically supervised injecting centre, naloxone

Inquest into the death of Tyson MATTHEWS (411.2 KB,PDF File)

Decision of Deputy State Coroner Stone

Coronial law, Self-inflicted death, involuntary admission considerations, risk assessment and suicide predictabilit, the use of Paliperidone, level of care in

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