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 41 - 50 of 63 results

Inquest into the death of Jasmynd Gibbs (813.1 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – death due to complications of methylamphetamine use; death of a person on supervised parole; wrap around support for parolees with complex needs

Inquest into the death of Glen Russell (302.1 KB,PDF File)

Decision of Deputy State Coroner Stone

Coronial law, death in custody; asphyxia; adequacy of intake screening and assessment; workload and staffing; recommencing medication prescribed in the communi

Inquest into the death of Christopher McGRAIL (454.6 KB,PDF File)

Decision of Deputy State Coroner Truscott

CORONIAL LAW; cause and manner of death, s.23 death as a result of a police operation, police tactical training, police mental health training, gunshots, subst

Inquest into the death of Edward Haenga (683.1 KB,PDF File)

Decision of Deputy State Coroner Lee

Coronial law, death in custody, psychotropic medication, QT interval prolongation, metabolic monitoring, metabolic syndrome, Junee Correctional Centre, cardiac

Inquest into the death of Eeva DORENDAHL and Greg HUTCHINGS (506.7 KB,PDF File)

Decision of Acting State Coroner O'Sullivan

Coronial law, cause and manner of death, unknown cause, likely drug overdose, suicide, death of child by actions of father

Inquest into the death of Maureen Smith (1.3 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Glen Innes District Hospital, Armidale Rural Referral Hospital, referral of medical practitioner to the Medical Council of NSW, signs of clinica

Inquest into the death of Brian Raymond Peters, one of the Balibo Five (564.0 KB,PDF File)

Coronial law - jurisdiction, background to attack on Balibo, attack, warnings and opportunities to escape, Indonesian and Australian knowledge of attack, cover

Inquiry into the fire at Reedy Swamp Tarraganda Bega/Tathra (1.3 MB,PDF File)

Decision of Deputy State Coroner Truscott

CORONIAL LAW - Fire General Inquiry - Cause and Origin - Electrical Infrastructure-Vegetation Management - Fuel Load Management - Emergency Response Management

Inquest into the death of Bailey Mackander (595.6 KB,PDF File)

Decision of Deputy State Coroner Truscott

Coronial law, cause and manner of death, First Nations death whilst in lawful custody of Corrective Services NSW, Hospital escort, Escape , Intent to self-harm

Inquest into the deaths at Newmarch House (2.5 MB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, COVID-19 pandemic, residential aged care facility, preparedness for infectious disease outbreak, surge workforce, Per

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