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 931 - 940 of 975 results

Inquest into the death of Mandaswamy SHANKARANARAYANA (162.8 KB,PDF File)

Decision of Deputy State Coroner Dillon

Coronial law, death in custody, cause and manner of death, suicide while on remand for homicide charge (see inquest into death of Leonie Felix)

Inquest into the disappearance and suspected death of Jessica Beth SMALL (166.0 KB,PDF File)

Decision of Deputy State Coroner Freund

Coronial law, missing person, suspicious death, reward

Inquest into the death of Gary McKell (65.5 KB,PDF File)

Decision of State Coroner Barnes

Coronial law, cause and manner of death, violent, unnatural death, assault, self defence

Inquest into the death of Beryl Joyce WATSON (117.2 KB,PDF File)

Decision of State Coroner Barnes

Coronial law, short stay aged care residents, caring for non commutive patients in aged care facility

Inquest into the death of GB (88.2 KB,PDF File)

Decision of Deputy State Coroner Dillon

CORONIAL LAW - death in custody, cause and manner of death, suicide, remand prisoner, not caused by systemic or human error

Inquest into the death of Adam HAYWARD (153.0 KB,PDF File)

Decision of Deputy State Coroner Freund

Coronial law, borderline personality disorder, care and treatment, psychiatric care, liverpool hospital mental health unit

Inquest into the death of Tama GALIERE (117.2 KB,PDF File)

Decision of Deputy State Coroner Dillon

Coronial law, Cause and manner of death, Hospital death,-   Whether procedure for inserting central line was appropriate given the diagnosis, Whether procedure

Inquest into the death of Brendan BURNS (244.7 KB,PDF File)

Decision of Deputy State Coroner Dillon

Coronial law, Cause and manner of death, Hospital death, Misdiagnosis of seriously-ill patient in emergency department, Failure to identify patient as critical

Inquest into the death of Hugh David LISLE (298.7 KB,PDF File)

Decision of State Coroner Barnes

Coronial law, mental health patients, clinical supervision, CPR in psychiatric institutions

Inquest into the death of Leslie ARMSTRONG (127.5 KB,PDF File)

Decision of Deputy State Coroner Forbes

Coronial law, residential aged care facility, balcony fall due to failure of safety railing, recommendations to Minister for Planning

Last updated:

02 May 2025