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 34 results

  • Recommended
    Decision of Deputy State Coroner Lee
    CORONIAL LAW - manner of death
  • Recommended
    Decision of Deputy State Coroner Huntsman
    CORONIAL LAW - unlicenced shooters; try shooting course; P650 forms; Firearms Registry oversight; notification procedures; risk of harm to self or others; clauses 101 and 104 of Firearms Regulation 2017
  • Recommended
    Decision of Deputy State Coroner Huntsman
    CORONIAL LAW - mental health and substance abuse disorder; risk of harm to self or others; firearms licence; medical assessment process
  • 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
Page 1 of 4
Last updated:

12 Nov 2021

Was this content useful?
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
Thank you for your feedback.
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