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.

Search

Filters

Search results

Showing results 931 - 940 of 971 results

Inquest into the death of GB (88.2 KB,PDF File)

Decision of Deputy State Coroner Dillon

CORONIAL LAW - death in custody, cause and manner of death, suicide, remand prisoner, not caused by systemic or human error

Inquest into the death of Adam HAYWARD (153.0 KB,PDF File)

Decision of Deputy State Coroner Freund

Coronial law, borderline personality disorder, care and treatment, psychiatric care, liverpool hospital mental health unit

Inquest into the death of Tama GALIERE (117.2 KB,PDF File)

Decision of Deputy State Coroner Dillon

Coronial law, Cause and manner of death, Hospital death,-   Whether procedure for inserting central line was appropriate given the diagnosis, Whether procedure

Inquest into the death of Brendan BURNS (244.7 KB,PDF File)

Decision of Deputy State Coroner Dillon

Coronial law, Cause and manner of death, Hospital death, Misdiagnosis of seriously-ill patient in emergency department, Failure to identify patient as critical

Inquest into the death of Hugh David LISLE (298.7 KB,PDF File)

Decision of State Coroner Barnes

Coronial law, mental health patients, clinical supervision, CPR in psychiatric institutions

Inquest into the death of Leslie ARMSTRONG (127.5 KB,PDF File)

Decision of Deputy State Coroner Forbes

Coronial law, residential aged care facility, balcony fall due to failure of safety railing, recommendations to Minister for Planning

Inquest into the death of Elijah HOLCOMBE (249.3 KB,PDF File)

Decision of State Coroner Jerram

Coronial law, mental illness, police procedures when dealing with, shooting by police

Inquest into the death of SS (134.3 KB,PDF File)

Decision of State Coroner Barnes

CORONIAL LAW - self inflicted death, access to toxic chemicals, Poisons and Therapeutic Goods Act.

Inquest into the death of Jordan Leigh SARGENT (65.7 KB,PDF File)

Decision of State Coroner Barnes

CORONIAL LAW - Death in care, supervision of a person with a disability, choking on food.

Inquest into the death of Reece POTTER (102.5 KB,PDF File)

Decision of Deputy State Coroner Dillon

CORONIAL LAW - cause and manner of death, horse racing accident, why horse fell mid-race? Whether horse struck marker post before or after falling? Whether cou

Last updated:

02 May 2025