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 21 - 30 of 975 results

Inquest into the death of ML (1.3 MB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Death of 17 month old First Nations child - family known to DCJ - staffing and resources at DCJ - domestic violence - need for multiagency coope

Inquest into the death of Harmony (1.7 MB,PDF File)

Decision of Deputy State Coroner Grahame

CORONIAL LAW – intentionally self-inflicted death; death of a young person; family violence and neglect – family known to the NSW Department of Communities and

Inquest into the death of Alan Green (343.0 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW – Death as a result of police operations; NSW police application of policies and procedures in relation to motor vehicle pursuits.

Inquest into the death of Cameron De Vries (407.9 KB,PDF File)

Decision of Deputy State Coroner Hosling

CORONIAL LAW – s 24(1)(e) Coroners Act 2009 (NSW), disability support services, the need for risk identification and assessment, the interaction between the vi

Inquest into the death of Heather Winchester (1.8 MB,PDF File)

Decision of Deputy State Coroner O'Neil

CORONIAL LAW – elective surgery, informed consent, Jehovah’s witness, documents indicating wishes, documents prepared in USA, unsuitability of documents for NSW

Inquest into the death of Jyedon Pollard (785.6 KB,PDF File)

Decision of Deputy State Coroner Forbes

CORONIAL LAW - Dog attack of a two-year-old boy - Examination of the Companion Animals Act 1998 regulatory regime - Recommendations for regulatory changes

Inquest into the death of Alfonso Ceniccola (372.5 KB,PDF File)

Decision of Deputy State Coroner Ryan

CORONIAL LAW – death in custody – care and treatment – requirements and frequency of physical observations – policies, procedures, and training applicable to s

Inquest into the death of David Freeman (2.9 MB,PDF File)

Decision of Deputy State Coroner Baptie

CORONIAL LAW – Respiratory arrest, bronchial asthma, known sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs), non-allergic hypersensitivity reactio

Inquest into the death of Daniel Munro Lewis Turnbull (550.5 KB,PDF File)

Decision of Deputy State Coroner Kennedy

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, natural causes, need to deliver treatment, 24 hour surveillance cell, RIT, mental illn

Inquest into the death of IE (443.1 KB,PDF File)

Decision of Deputy State Coroner Hosking

CORONIAL LAW- Cause and manner of death, intentional self-harm, policies and procedures for transfer of involuntary patients between hospital/mental health fac

Last updated:

02 May 2025