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 31 - 40 of 970 results

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

Inquest into the death of BG (449.2 KB,PDF File)

Decision of Deputy State Coroner Pearce

CORONIAL LAW – death of 7-month-old baby – family known to Department of Communities and Justice – cause and manner of death

Inquest into the death of MJ (1.1 MB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW- Dog attack of a five-week-old baby- Examination of the Companion Animals Act 1998 regulatory regime – Recommendations for regulatory changes

Inquest into the death of Tammy Michelle Shipley (599.0 KB,PDF File)

Decision of State Coroner O'Sullivan

CORONIAL LAW - interlocutory application, jurisdiction, sufficient interest, issues list, interim hearing, scope, recommendations

Inquest into the death of Logan Losurdo (182.9 KB,PDF File)

Decision of Magistrate K Perry, Coroner

CORONIAL LAW – unascertained manner of death; unascertained cause of death; evidence incapable of meaningful examination due to time in water

Inquest into the death of Ian Turner (3.6 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – intentional self-harm – multi-drug toxicity – Post Traumatic Stress Disorder (PTSD) – combat-related PTSD – mental health supports for ADF membe

Inquest into the death of Olivia Gilffillan (333.8 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW - Can cause and manner of death be established? Mental health diagnosis and treatment; medical response to suicide risk

Inquest into the death of Stephen John Burt (325.0 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW - identification of a missing person, NSW police application of policies and procedures in relation to missing persons and fingerprinting

Inquest into the death of Mr S (266.4 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – mandatory inquest – death of a person in lawful custody – self-inflicted intentional death

Last updated:

02 May 2025