Coronial findings and recommendations

CORONIAL LAW – diagnosis of mental health condition – psychotic depression / depression with psychotic features – care and treatment provided during admission at Nolan House including adequacy of risk assessments, observations, and treatment

CORONIAL LAW – mid-gut volvulus and bowel obstruction, ischaemic bowel, unconscious bias, consideration of disability and treatment in hospital, Bathurst Base Hospital, adequacy of care, NETS, provision of care to children in rural NSW

CORONIAL LAW – cause and manner of death, exertional heat stroke, exertional heat illness, hyperthermia, seizures, National Rugby League, Heat Policy, Manly Warringah Sea Eagles, Heat Stress Index, Kestrel Heat Stress Tracker, cooling strategies,

CORONIAL LAW – Aboriginal; First Nations; Wakamurra; Muruwari; Kunya; Bourke; Enngonia; single vehicle collision; rollover; inquest resumed; s.79 Coroners Act; colonisation; racism; Police Guidelines for the review of investigations relating to

CORONIAL LAW – manner and cause of death – mental illness – family violence and neglect – family known to the NSW Department of Communities and Justice and the QLD Department of Child Safety, Seniors and Disability Service – neglect –

CORONIAL LAW – Death in police operation – death as a result of a fall from height – borderline personality disorder – BPD – Dialectical Behaviour Therapy – DBT – Blue Mountains Hospital – benzodiazepines

CORONIAL LAW – cause and manner of death of a baby at birth–ultrasound report- continuous CTG monitoring-caesarean section-separation of the umbilical cord-transected placenta-NICU response

CORONIAL LAW - cause and manner of death, homicide

CORONIAL LAW – Death in police operation – gunshot wounds by police officer – appropriateness of actions of NSW Police Force officers – use of “breach and hold” in a police operation involving a person suffering from an acute episode of

CORONIAL LAW - Cause and manner of death - open finding as to manner - cause of death acid burns - application of acid by another - immigration fraud - gambling - debts