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 51 - 60 of 63 results

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 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 Baylen Pendergast (550.2 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW - suspicious death of a child, cause and nature of paediatric head injuries, whether head injuries were non-accidental, care provided at Tamworth

Inquest into the death of JY (475.1 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - acute psychotic episode, schizophrenia, was mental health care appropriate, recommendations to expand REACH program in public mental health sett

Inquest into the death of Carley METCALFE (624.4 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - cause of death; search for missing person in Mullumbimby; adequacy of police investigation; Missing Persons Standard Operating Procedures; care

Inquest into the death of A P (742.5 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW; Management of Risk to Child where Parent has Acute Mental Health Disorder; Child Protection File Closure Policy; Mental Health Care Co-ordination

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1 (7.5 MB,PDF File)

Decision of State Coroner O'Sullivan

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1

Inquest into the death of Stanley Leonard RUSSELL (557.8 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW - manner of death, death in the course of a police operation, police executing a bench arrest warrant, planning and risk assessment, discharges of

Inquest into the death of Tristan Naudi (520.5 KB,PDF File)

Decision of State Coroner Magistrate Teresa O’Sullivan

CORONIAL LAW – manner and cause of death – MDMA intoxication – restraint – physiological stress

Inquest into the death of Huy Neng Ngo (1.5 MB,PDF File)

Decision of Deputy State Coroner Truscott

Coronial law, defective Takata airbags, product safety, voluntary recall

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