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 11 - 20 of 967 results

Inquest into the death of Brent Pottinger (376.8 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – death as a result of fall from height, NSW Police operation, apprehended domestic violence order, appropriateness of NSW Police response

Inquest into the death of Fiona Turnbull (349.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information ex

Inquest into the death of Muhammad Hafizuddin Bin Zaini (311.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of person in immigration detention – self-inflicted intentional death – was mental health care adequate – were there adequate communicatio

Inquest into the death of Leah Jane Porter (678.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – approp

Inquest into the death of Moses Kellie (574.6 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person in immigration detention – were mental health care services adequate – was monitoring by detention staff adequate - is there a

Inquest into the death of Harmony (1.7 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – intentionally self-inflicted death; death of a young person; family violence and neglect – family known to the NSW Department of Communities and

Inquest into the death of Alan Green (343.0 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW – Death as a result of police operations; NSW police application of policies and procedures in relation to motor vehicle pursuits.

Inquest into the death of Cameron De Vries (407.9 KB,PDF File)

Decision of Deputy State Coroner Hosling

CORONIAL LAW – s 24(1)(e) Coroners Act 2009 (NSW), disability support services, the need for risk identification and assessment, the interaction between the vi

Inquest into the death of Heather Winchester (1.8 MB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – elective surgery, informed consent, Jehovah’s witness, documents indicating wishes, documents prepared in USA, unsuitability of documents for NSW

Inquest into the death of Jyedon Pollard (785.6 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW - Dog attack of a two-year-old boy - Examination of the Companion Animals Act 1998 regulatory regime - Recommendations for regulatory changes

Last updated:

02 May 2025