Coronial findings 

To access a finding not listed here, please make application (DOC , 61.5 KB) to the Court. In some inquests recommendations are made to Ministers and Government and non-government agencies.

Showing 1-10 of 31 results

  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - Cycling death - bicycle helmet - star system rating with respect to bicycle helmets
  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - Death as a result of a police operation - traffic stop - L plater
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - care and treatment; Ryde Hospital; Macquarie Hospital; Lavender House; concurrent administration of contraindicated medication; verapamil; metoprolol; electronic prescription system; eMeds; pharmacist review; discharge summary
  • Recommended
    Decision of Deputy State Coroner Huntsman
    Coronial law, missing persons, helicopter crash, pilot error, spatial disorientation, weather conditions
  • Recommended
    Decision of Deputy State Coroner Ryan
    CORONIAL LAW - death of a child in the course of a police pursuit; should the police's covert investigation of the driver have been allowed to continue; was the planning for an intercept of the driver adequate; should police vehicles have
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody; cause and manner of death
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - mother/child homicide/suicide; Borderline Personality Disorder/complex post-traumatic stress disorder; Alprazolam; child protection; adequacy of handover process between caseworkers
  • Recommended
    Decision of Deputy State Coroner Forbes
    Coronial law, missing person since 1958
  • Recommended
    Decision of Deputy State Coroner Lee
    Coronial law, care and treatment, Fairfield Hospital, left total knee replacement surgery, superior mesenteric artery tent, coeliac artery stent, vascular consult, pre-admission clinic, pre-operative care, medical clearance prior to surgery
  • Recommended
    Decision of Deputy State Coroner Huntsman
    Coronial law, death in custody, cause of death is consistent with history of hanging, first time in custody and on remand, role of Justice Health and Forensic Mental Health Network
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Last updated:

12 Nov 2021

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