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 21 - 30 of 967 results

Inquest into the death of Alfonso Ceniccola (372.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death in custody – care and treatment – requirements and frequency of physical observations – policies, procedures, and training applicable to s

Inquest into the death of David Freeman (2.9 MB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reactio

Inquest into the death of Daniel Munro Lewis Turnbull (550.5 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, natural causes, need to deliver treatment, 24 hour surveillance cell, RIT, mental illn

Inquest into the death of IE (443.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW- Cause and manner of death, intentional self-harm, policies and procedures for transfer of involuntary patients between hospital/mental health fac

Inquest into the death of unidentified human remains found at Sutherland (260.3 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – identity, unidentified remains, forensic investigative genetic genealogy

Inquest into the death of Mohamed Syed Ahamed (2.3 MB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW - death as a result of police shooting - was police use of force consistent with policy and training - was police response in preceding days appro

Inquest into the death of Stephen Paul Bourke (173.4 KB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – death in custody – mandatory inquest – natural death

Inquest into the disappearance and suspected death of KHL (267.6 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – whether missing person now deceased, date and place of death, cause and manner of death, rock fishing, Eagle Rock, Royal National Park

Inquest into the Death of Robert Driver (148.7 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, homicide, resident of aged care facility, challenging behaviour of resident, clinical management, indication for tran

Inquest into the deaths at Newmarch House (2.5 MB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, COVID-19 pandemic, residential aged care facility, preparedness for infectious disease outbreak, surge workforce, Per

Last updated:

02 May 2025