Coronial findings and recommendations

To access a finding not listed here, please make application (DOC, 62.0 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 1-10 of 92 results

Recommended

Inquest into the death of Timothy Ricketts

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Unascertained death, recent cardiac event with raised troponin levels, significance of Pfizer vaccination, effects of methadone use on cardiac disease, effects of decomposition affecting autopsy.
Recommended

Inquest into the disappearance and presumed death of James Richard Dang

Decision of Deputy State Coroner O'Neil

CORONIAL LAW - missing person, search
Recommended

Inquest into the death of Philip Nguyen

Decision of Deputy State Coroner Baptie

CORONIAL LAW- death in custody, cause and manner of death
Recommended

Inquest into the death of CC

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – High Dependency Unit, psychiatric care, Nepean Hospital, self-harm in psychiatric ward, Mentally ill person, reduction of hanging points, highlighting of events in medical records
Recommended

Inquest into the death of TH

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – death in custody, self-inflicted
Recommended

Inquest into the disappearance and suspected death of William Mainprize

Decision of Deputy Chief Magistrate Freund

CORONIAL LAW – disappearance, Gulf Livestock 1, Typhoon, Sinking
Recommended

Inquest into the Death of Andrew James Chee Quee - Decision

Decision of Deputy State Coroner Grahame

CORONIAL LAW – interlocutory application – recusal application – application for the Coroner to disqualify herself as the presiding coroner in the inquest – apprehension of bias – Coroner’s adult sister’s public discussion of police
Recommended

Inquest into the death of Jacob Carr

Decision of Deputy State Coroner Baptie

CORONIAL LAW – death in police operation – gunshot wound inflicted by police officer – appropriateness of actions of NSW Police Force officers – adequacy of care and treatment provided by NSW Ambulance
Recommended

Inquest into the death of Andrew Stark

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – police pursuit, death in police operation, decision to initiate police pursuit, relevance of seriousness of offending, conduct of driving, Safe Driving Policy (SDP)
Recommended

Inquest into the death of SB

Decision of Deputy State Coroner O'Neil

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

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Coronial findings and recommendations

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