Coronial findings and recommendations

To access a finding not listed here, please make application (DOC, 62.0 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 71-79 of 79 results

Recommended

Inquest into the death of Francis Sawle

Decision of Deputy State Coroner Magistrate Harriet Grahame

CORONIAL LAW – Death in custody, natural causes
Recommended

Inquest into the death of Neville Clutton

Decision of Deputy State Coroner Magistrate Stone

CORONIAL LAW – Manner of death – Residential Aged Care Facility – Resident to Resident Aggression in dementia unit – policies and procedures – identifying cause of behaviour and reporting incidents – actions taken to prevent escalation
Recommended

Inquest into the death of Chella Leijten

Decision of

CORONIAL LAW – involuntary patient, Mental Health Act 2007, natural cause death
Recommended

Inquest into the death of Francis McCann

Decision of Deputy State Coroner Magistrate Derek Lee

CORONIAL LAW - death in custody; accidental fall; Metropolitan Special Purpose Centre; Complex Monitor Room
Recommended

Into the death of Neville Raymond Towner

Decision of Deputy State Coroner E.Truscott

Coronial Law-natural causes death in lawful custody
Recommended

Inquest into the death of OS

Decision of Deputy State Coroner Magistrate Derek Lee

CORONIAL LAW - cause and manner of death; oral sedation; observations; respiratory depression; SUDEP; valproic acid; bioavailability of morphine
Recommended

Inquest into the death of Andrew Ngo

Decision of Deputy State Coroner Magistrate Elizabeth Ryan

CORONIAL LAW – death following police pursuit – whether involved police officers complied with applicable policies – whether police pursuit caused or contributed to Andrew Ngo’s death - recommendations.
Recommended

Inquest into death of MW

Decision of Deputy State Coroner E. Truscott

Coronial Law-Cause and manner of death
Recommended

Into the death of Thomas Redman

Decision of Magistrate Ross Hudson

CORONIAL LAW - cause and manner of death - catastrophic injury - rural emergency response - pre hospital transfer

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Coronial findings and recommendations

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