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 - external site are made to Ministers and Government and non-government agencies.

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Showing 11-20 of 82 results

  • Recommended

    Inquest into the death of Danny Whitton

    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death,death in custody. First Nations Prisoner, paracetamol toxicity, delay, CCTV
  • Recommended

    Inquest into the death of Albert Metledge

    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death
  • Recommended

    Inquest into the death of Emiliana OBUSAN

    Decision of Deputy State Coroner Lee
    CORONIAL LAW - cause and manner of death - endotracheal tube - unrecognised oesophageal intubation - tracheal intubation - provision of anaesthesia care to paediatric patients - qualifications and experience of paediatric anaesthetists - end tidal
  • Recommended

    Inquest into the death of Huy Neng Ngo

    Decision of Deputy State Coroner Truscott
    Coronial law, defective Takata airbags, product safety, voluntary recall
  • Recommended

    Inquest into the death of James Sampson DORAN

    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - Death in custody, natural causes
  • Recommended

    Inquest into the death of Conway PERRIE

    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody, cause and manner of death
  • Recommended

    Inquest into the death of Jack KING

    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - Death in custody, natural causes
  • Recommended

    Inquest into the death of Caitlin CRUZ

    Decision of Deputy State Coroner Lee
    CORONIAL LAW - Cause and manner of death, information transfer from a pre-hospital setting to hospital setiting, referral letter to hospital, senior clinician review, pericarditis, patient handover, triage, Ambulance Electronic Medical Record,
  • Recommended

    Inquest into the death of Walter CLOUGH

    Decision of Deputy State Coroner Ryan
    CORONIAL LAW - death of a person in lawful custody - adequacy of custodial health care
  • Recommended

    Inquest into the death of Jesse DRABSCH

    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - accidental death after use of insulin, Performance and Image Enhancing drugs (PIEDs), Insulin, death in 24 hour gym
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Last updated:

31 Mar 2025

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