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.

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Showing results 11 - 20 of 975 results

Inquest into the death of NL (483.3 KB,PDF File)

Decision of Deputy State Coroner Lee

CORONIAL LAW – cause and manner of death, cardiac arrythmia, QT prolongation, hypothyroidism, compliance with thyroxine medication, endocrine management, thyro

Inquest into the death of Michelle Michell (4.1 MB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - cross

Inquest into the death of Bernard Greenwell (398.8 KB,PDF File)

Decision of Deputy State Coroner Franklin

CORONIAL LAW - death in custody, cause and manner of death

Inquest into the death of HC (242.3 KB,PDF File)

Decision of Deputy State Coroner O’Neil

CORONIAL LAW – missing person –overboard from boat –search –not possible to survive –

Inquest into the death of Warren Simon (495.5 KB,PDF File)

Decision of Deputy State Coroner Pearce

CORONIAL LAW – death as a result of police operation – First Nations man – appropriateness of police response

Inquest into the death of Brent Pottinger (376.8 KB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – death as a result of fall from height, NSW Police operation, apprehended domestic violence order, appropriateness of NSW Police response

Inquest into the death of Fiona Turnbull (349.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information ex

Inquest into the death of Muhammad Hafizuddin Bin Zaini (311.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of person in immigration detention – self-inflicted intentional death – was mental health care adequate – were there adequate communicatio

Inquest into the death of Leah Jane Porter (678.2 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – approp

Inquest into the death of Moses Kellie (574.6 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death of a person in immigration detention – were mental health care services adequate – was monitoring by detention staff adequate - is there a

Last updated:

02 May 2025