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 82 results

  • Recommended
    Decision of Deputy State Coroner Forbes
    CORONIAL LAW - cause and manner of death - medical care and treatment of long-term mental health patients - prescribing of anti-psychotic and sedative medication - choking on food
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - Cause and manner of death, identity of deceased persons, NSW Public Guardian, Dubbo Base Hospital, Lourdes Hospital and Community Health Care Service, NSW Civil and Administrative Tribunal, guardianship application, Aged Care
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - cause and manner of death, early childhood education and care, family day care, regulatory authority, Kidstart Pty Ltd, Department of Education, safe sleeping practices for infants and babies, persistent pulmonary
  • Recommended
    Decision of State Coroner O'Sullivan
    CORONIAL LAW - traffic incident, five deaths, manner of driving, methadone dispensing, impact of various medications, adequacy of treatment in regional areas, expert evidence
  • Recommended
    Decision of Deputy State Coroner Grahame
    CORONIAL LAW - Sudden Unexpected Death in Infancy (SUDI), frusemide
  • Recommended
    Decision of Deputy State Coroner Truscott
    CORONIAL LAW - Fire General Inquiry - Cause and Origin - Electrical Infrastructure-Vegetation Management - Fuel Load Management - Emergency Response Management Communication and Co-ordination - Provision of Resources - Rural Fire Service -
  • Recommended
    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death, First Nations death whilst in lawful custody of Corrective Services NSW, Hospital escort, Escape , Intent to self-harm, Risk Intervention Team treatment
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody, self-inflicted death, Metropolitan Special Programs Centre, psychiatric review, Patient Administration System, Darcy Daily Clinic Tracker Sheet, cell architecture, ligature points, cell placement
  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - death in custody, cause and manner of death
  • Recommended
    Decision of Deputy State Coroner Truscott
    Coronial law, cause and manner of death,death in custody. First Nations Prisoner, paracetamol toxicity, delay, CCTV
Page 1 of 9
Last updated:

12 Nov 2021

We will use your rating to help improve the site.
This field is required
Please don't include personal or financial information here
This field is required
Please don't include personal or financial information here
We acknowledge the traditional owners and custodians of the land on which we work and we pay respect to the Elders, past, present and future.
Return to top of page Back to top