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.

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Showing results 101 - 110 of 971 results

Inquest into the death of WM (156.4 KB,PDF File)

Decision of Deputy State Coroner Baptie

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

Inquest into the death of RA (576.7 KB,PDF File)

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

Inquest into the suspected death of Florabella Natalia Marion Remakel, aka Marion Barter (967.0 KB,PDF File)

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 dea

Inquest into the disappearance of Robert Hamish Duncan (350.7 KB,PDF File)

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

Inquest into the death of Natasha Lechner (767.1 KB,PDF File)

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

Inquest into the death of Jasmynd Gibbs (813.1 KB,PDF File)

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

Inquest into the death of Siosiua Mateaki He Lotu Meyer (262.5 KB,PDF File)

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

Inquest into the death of Omar Mohammad (671.8 KB,PDF File)

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 ex

Inquest into the death of Timothy Garner (310.9 KB,PDF File)

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 architect

Inquest into the death of Subash Subedi (191.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – disappearance and death - can manner and cause of death be ascertained

Last updated:

02 May 2025