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 121 - 130 of 971 results

Inquest into the death of Andrew Stark (345.1 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – police pursuit, death in police operation, decision to initiate police pursuit, relevance of seriousness of offending, conduct of driving, Safe

Inquest into the death of SB (256.0 KB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW— mental health issues, police operation, siege, negotiations

Inquest into the death of DP (962.1 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – Death in custody; self-inflicted death; hanging in correctional centre; requests for medical treatment; sleep apnoea; obtaining CPAP machines in

Inquest into the death of DO (188.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death as a result of fall from a height - – the manner of death – was police response appropriate

Inquest into the death of Adam Fitzpatrick (1.2 MB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, tracheostomy management, tracheostomy tube dislodgment, complex airway, bronchoscopy, monitoring of patient, rocuroni

Inquest into the death of Steven McHugh (229.3 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – death in custody – mandatory inquest – intentional self harm – plastic bags

Inquest into the death of Melville Schrader (267.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a man in lawful custody – requests for medical treatment – was response of the JH Network appropriate – would a more timely response ha

Inquest into the death of John O'Donnell (303.6 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – death in custody – mandatory inquest – cell placement – whether medical condition adequately managed

Inquest into the death of Wayne Mullin (167.3 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – unascertained death, affects of splenic toxicology, effects of oxycodone and diazepam on respiratory illness, effects of significant decompositi

Inquest into the death of Sandra Lee Cawthorne (231.0 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – fatal shooting of a woman in 2004 – perpetrator unable to be identified – referral to Unsolved Homicide Squad.

Last updated:

02 May 2025