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 241 - 250 of 975 results

Inquest into the death of M G (350.4 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW - Manner of Death - Suicide Intervention - Police Operation - Appropriateness and adequacy of police response - Intentional taking of life

Inquest into the disappearance of CD (366.7 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Missing person – manner of death – Police Investigation – Appropriateness and adequacy of police response – Appropriateness of legislative inter

Inquest into the death of Ian Fackender (586.4 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - manner of death - death in the course of a police operation - police operation to enforce Community Treatment Order under Mental Health Act 2007

Inquest into the death of Sophia Bolshesolsky (379.8 KB,PDF File)

Decision of DSC Forbes

CORONIAL LAW - Pedestrian death - should the NSW Police Crash Investigation Unit have been called to investigate the accident - safety for pedestrians in John

Inquest into the death of Gavin Ellis (1.5 MB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW - self-inflicted death in custody - mandatory inquest - adequacy of mental health care - Care Pathways Model for Custodial Mental Health - Renewed

Inquest into the death of LAK (1.0 MB,PDF File)

Decision of Deputy State Coroner Huntsman

CORONIAL LAW, young First Nations man, death in residential drug rehabilitation facility, forensic patient order, cultural safety in provision of health servic

Inquest into the death of Phoenix Hemmings (213.0 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW, cause and manner of death, methadone prescription and dispensing, takeaway dose, opioid treatment program, safety assessment and safety planning

Inquest into the death of Michael Quinn (196.8 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW, natural causes death in custody, care and treatment of quadriplegic inmate in custody

Inquest into the death of Robert Bischard (407.8 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW, cause and manner of death, care and treatment at Wagga Wagga Base hospital, pre-operative screening processes in the context of co-morbidities

Inquest into the death of Vivian David Anderson (146.2 KB,PDF File)

Decision of Deputy State Coroner Kennedy

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

Last updated:

02 May 2025