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 1148 results

Inquest into the disappearance of Hyungwoo PARK (246.9 KB ,PDF File)

Decision of Deputy State Coroner, Judge David O’Neil

CORONIAL LAW – missing person—police investigation—limited searches due to late report to police—sign of life checks

Inquest into the death of Leslie Andrew Nash (1.1 MB ,PDF File)

Decision of Judge Harriet Grahame, Deputy State Coroner

CORONIAL LAW – Gunshot wound to the head, “manner of death”, open finding

Inquest into the death of Ivan Spudic (344.5 KB ,PDF File)

Decision of Judge David O’Neil, Deputy State Coroner

CORONIAL LAW - unascertained manner and cause, unreliable admissions made by partner

Inquest into the disappearance and presumed death of Jessica Jade Zrinski (517.4 KB ,PDF File)

Decision of Deputy State Coroner, Judge David O’Neil

CORONIAL LAW – missing person, police investigation, suspicious circumstances, whether missing person is deceased, whether findings came be made about date, pl

Inquest into the death of Pippa Mae White (6.8 MB ,PDF File)

Decision of Judge Joan Baptie, Deputy State Coroner

CORONIAL LAW – cause and manner of death, Paediatric Sepsis Pathway, delayed diagnosis, escalation of care

Inquest into the deaths of Richard Caskey & Michael Waldon (442.9 KB ,PDF File)

Decision of Judge Derek Lee, Deputy State Coroner

CORONIAL LAW – manner of death, aviation accident, gyroplane impact with terrain, rotor blade design and manufacture, ejection of balance rod, integrity of adh

Inquest into the death of Emily Warn (739.0 KB ,PDF File)

Decision of Judge Carmel Forbes, Deputy State Coroner

CORONIAL LAW – Boat capsize over the Penrith Weir-Subsequent drowning - Missing safety buoys barrier at the weir -Issues with the inspection and replacement of

Inquest into the death of Kenneth Toll (501.2 KB ,PDF File)

Decision of Judge Sally McLaughlin, Coroner

Cause of death; pulmonary thromboembolism following bilateral knee replacement surgery; recognition of post-surgery symptoms; requirement for referral for spec

Inquest into the death of Steve Pampalian (763.2 KB ,PDF File)

Decision of Judge Kasey Pearce, Deputy State Coroner

CORONIAL LAW - death as a result of police operation –– shooting - mental health - appropriateness of police response

Inquest into the death of Thumbarian Govender (208.7 KB ,PDF File)

Decision of Judge R. Hosking, Deputy State Coroner

CORONIAL LAW - Natural death in custody

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