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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Inquest into the death of Margaret Mariani (455.5 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – complications of cholecystectomy surgery – grossly inadequate care and treatment provided at Forster Private Hospital – inadequate monitoring an

Inquest into the death of Wilfred Whippy Williams (533.9 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Discretionary inquest – death of First Nations man following emergency presentation to Cowra District Hospital – deceased did not wait during tr

Inquest into the death of Allyson Bailey (455.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

Coronial inquest, unanticipated death in hospital , interaction between provision of physical and mental health treatment, impact of Covid-19 on hospital care.

Inquest into the death of Stephen Douglas (607.8 KB,PDF File)

Decision of Deputy State Coroner Pearce

CORONIAL LAW – mental health-homicide-community mental health treatment – mental health policy and practice

Inquest into the death of Jacob (802.5 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Child Abuse, unexplained death of an infant, methylamphetamine, failure to protect child from harm, presentation to hospital with unexplained in

Inquest into the death of Bruce John Hitchen (309.4 KB,PDF File)

Decision of Deputy State Coroner Devine

CORONIAL LAW – whether missing person deceased – changes to missing person investigations - unascertained cause, manner, and place of death

Inquest into the death of Hilary Gordon-Squire (135.1 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Unascertained death

Inquest into the death of PF (299.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW – Mandatory inquest pursuant to s 23(1)(d)(ii) of the Coroners Act 2009 (NSW) – Death in custody; intentional self-harm following adverse legal ad

Inquest into the death of James Cunneen (897.4 KB,PDF File)

Decision of DSC O'Neil

CORONIAL LAW — death in custody — inadequate staffing — one general practitioner for 1150 patients in custodial setting — chaotic delivery of health care in No

Inquest into the death of Prabha Arunkumar (1.3 MB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW --fatal stabbing of woman in 2015-perpetrator not identified-referral to unsolved homicide

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