Coroners Court New South Wales

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 11-20 of 22 results

  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW – Self-inflicted death; death in involuntary mental health care; psychiatric care; consideration of mental health care, and treatment provided by Hospital; search policy in inpatient mental health care; frequency of observation care
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW – long term missing person – whether missing person is deceased – whether findings with regards to identity, date, place, cause, and manner of death can be made – nature and adequacy of police investigation – circumstances of
  • Recommended
    Decision of State Coroner O'Sullivan
    Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1
  • Recommended
    Decision of Deputy State Coroner Baptie
    CORONIAL LAW – unexplained disappearance and whether missing person is now deceased, date and place, cause and manner of death
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW- Kambo frog -death following application of frog poison - unnecessary death - vulnerable person- delay in getting help - Triple O call
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW – death due to complications of methylamphetamine use; death of a person on supervised parole; wrap around support for parolees with complex needs
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW- death of a man in police custody did police take appropriate steps to obtain medical .assistance - would earlier medical assistance have improved prospects for survival.
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW – Death in custody; acute cocaine toxicity, first aid by police; adequacy of NSW Police first aid training; CPR: NSW Police access to automatic external defibrillators (AEDs)
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW – death in custody, cause and manner of death, risk assessment, psychiatric assessment, mental health review, self-inflicted death, cell architecture, Metropolitan Remand andamp; Reception Centre, Risk Intervention Team management, Mental
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW – disappearance and death - can manner and cause of death be ascertained
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Last updated:

05 Apr 2023

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