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.

Showing 1-10 of 82 results

Recommended

Inquest into the death of Shelley YOUNG

Decision of Deputy State Coroner Forbes

CORONIAL LAW - cause and manner of death - medical care and treatment of long-term mental health patients - prescribing of anti-psychotic and sedative medication - choking on food
Recommended

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

Decision of Deputy State Coroner Lee

CORONIAL LAW - Cause and manner of death, identity of deceased persons, NSW Public Guardian, Dubbo Base Hospital, Lourdes Hospital and Community Health Care Service, NSW Civil and Administrative Tribunal, guardianship application, Aged Care
Recommended

Inquest into the death of Jack LOH

Decision of Deputy State Coroner Lee

CORONIAL LAW - cause and manner of death, early childhood education and care, family day care, regulatory authority, Kidstart Pty Ltd, Department of Education, safe sleeping practices for infants and babies, persistent pulmonary hypertension of the
Recommended

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Decision of State Coroner O'Sullivan

CORONIAL LAW - traffic incident, five deaths, manner of driving, methadone dispensing, impact of various medications, adequacy of treatment in regional areas, expert evidence
Recommended

Inquest into the death of Harland SUTTON

Decision of Deputy State Coroner Grahame

CORONIAL LAW - Sudden Unexpected Death in Infancy (SUDI), frusemide
Recommended

Inquiry into the fire at Reedy Swamp Tarraganda Bega/Tathra

Decision of Deputy State Coroner Truscott

CORONIAL LAW - Fire General Inquiry - Cause and Origin - Electrical Infrastructure-Vegetation Management - Fuel Load Management - Emergency Response Management Communication and Co-ordination - Provision of Resources - Rural Fire Service - Fire
Recommended

Inquest into the death of Bailey Mackander

Decision of Deputy State Coroner Truscott

Coronial law, cause and manner of death, First Nations death whilst in lawful custody of Corrective Services NSW, Hospital escort, Escape , Intent to self-harm, Risk Intervention Team treatment
Recommended

Inquest into the death of Yohan WEPITIYA-GAMAGE

Decision of Deputy State Coroner Lee

CORONIAL LAW - death in custody, self-inflicted death, Metropolitan Special Programs Centre, psychiatric review, Patient Administration System, Darcy Daily Clinic Tracker Sheet, cell architecture, ligature points, cell placement
Recommended

Inquest into the death of Joshua Szczudlo

Decision of Deputy State Coroner Ryan

CORONIAL LAW - death of man in hospital following Łshoulder surgery - cause of death - was clinical care 1adequate - policies and procedures for bariatric patients
Recommended

Inquest into the death of Elias MELHEM

Decision of Deputy State Coroner Lee

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

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Coronial findings and recommendations

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