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 63 results

Inquest into the death of Alfonso Ceniccola (372.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death in custody – care and treatment – requirements and frequency of physical observations – policies, procedures, and training applicable to s

Inquest into the death of JX (483.5 KB,PDF File)

Decision of State Coroner Barnes

Coronial law, Suicide, mental health assessment, ED triage, police response

Inquest into the death of Omar Mohammad (671.8 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Death in custody; acute cocaine toxicity, first aid by police; adequacy of NSW Police first aid training; CPR: NSW Police access to automatic ex

Inquest into the death of DP (542.4 KB,PDF File)

Decision of State Coroner Magistrate Teresa O’Sullivan

CORONIAL LAW – Cause and manner of death – Methylamphetamine intoxication, s.23 Coroners Act, police shooting.

Inquest into the death of O A (379.5 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – death as a result of fall from height – police operation – whether police response was adequate and appropriate – whether care and treatment pro

Inquest into the death of Brandon Clark (378.4 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Death in police operation, stop and search, Section 21 LEPRA, exercise of power to arrest, Section 77 Bail Act 2013, breach of bail, decision to

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

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 death of Leah Jane Porter (678.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – approp

Inquest into the death of John Inman BALE (377.1 KB,PDF File)

Decision of Deputy State Coroner Grahame

Coronial law, death in a police operation, transfer and termination of a 000 call, self inflicted death.

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