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 18 results

  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - cause and manner of death - care and treatment - removal of CVC - delirium-hospital system changes
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - cause and manner of death, homicide
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW - manner of death, creation and verification of COPS Events re domestic violence incidents, NSW Police Force Domestic Violence Standard Operating Procedures, firearms licensing P650 scheme, "Commissioner's Permits", gun club
  • Recommended
    Decision of Deputy State Coroner Ryan
    Coronial Law - mandatory inquest, death of a person in custody, cause of death: ruptured brain aneurysm, did Justice Health and Forensic Mental Health Network and hospitals provide adequate care and treatment
  • Recommended
    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death, hit and run, rural road, identification of vehicle and mechanism of injury
  • Recommended
    Decision of Deputy State Coroner Forbes
    Coronial Law - death of a young person, in state care, of drug overdose in suspicious circumstances, inadequate evidence to suspend inquest and refer the matter pursuant to s.78 Coroners Act 2009, inadequate care of a child in the parental
  • Recommended
    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death, homicide in the home, domestic violence, arrest in China
  • Recommended
    Decision of Deputy State Coroner Ryan
    Coronial Law - mandatory inquest, death of a person in custody, cause of death bronchial asthma, was immediate response of custodial officers adequate, was ongoing asthma care adequate, recommendations
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - Death of a child, Death after multiple notifications of Risk of Significant Harm (ROSH), unsolved homicide, Weekly Allocation Meeting (WAM), "competing priorities", adequacy of FACS (now DCJ) response
  • Recommended
    Decision of Deputy State Coroner Ryan
    Coronial Law - death of inmate at Cooma Correctional Centre, cause of death multi-drug toxicity
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