Coroners Court New South Wales

Coronial findings and recommendations

To access a finding not listed here, please make an application (PDF, 112.1 KB) to the Court. In some inquests, recommendations are made to Ministers and Government and non-government agencies. For a full list of recent recommendations and responses, please go to this site.

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Showing results 1 - 10 of 1072 results

Inquest into the death of Gia Lam (410.6 KB,PDF File)

Decision of Deputy State Coroner Hosking

Midwifery Support Program (MSP); early discharge of mothers and babies; sepsis; undiagnosed UTI; use of interpreters.

Inquest into the death of Serena Lee (447.6 KB,PDF File)

Decision of Deputy State Coroner Hosking

Inquest into the death of Serena Lee

Inquest into the death of Evander Tuala (425.9 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW – manner of death-death during an affray-can a known person be identified as causing the death

Inquest into the death of Judith Ingham (836.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

Requirements regarding the installation of temperature control devices; Notifications to SafeWork NSW; Building Commission oversight of licensed plumbers; cont

Inquest into the death of Mustafa Kayirici (419.8 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW – mandatory inquest – death in custody – cause of death – medical care and treatment – end of life planning and care

Inquest into the death of Gregory Merriman (944.6 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – mandatory inquest – death of a First Nations man in custody – use of force event in response to other inmates fighting in a POD – deployment of

Inquest into the death of BX (929.9 KB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW - siege - negotiations - possession of firearm - unexecuted arrest warrant

Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy (510.2 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, dysphagia risk, choking risk, residential aged care facility, chewing and swallowing, International Dysphagia Diet St

Inquest into the death of Jeremy Webb (338.9 KB,PDF File)

Decision of Deputy State Coroner Forbes

Mammalian Meat Allergy after tick bite-awareness in hospitals and in the community-cause of death-severe allergic reaction-anaphylaxis-asthma

Inquest into the deaths of Jebriel Dandan and Seiffedine Malas (487.2 KB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – death in police operation – s 23 – police pursuit – motor-vehicle accident – fire/burns – high range speeding – motor vehicle crash – under infl

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