Coroner's Court

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Coronial findings

 
Coronial findings are listed below in descending date order.

 
In some inquests recommendations are made to Ministers and Government and non-government agencies. Where such recommendations are made to Ministers and Government agencies they are required to report to the Attorney General within six months of receiving a coronial recommendation, outlining any action to be taken to implement the recommendation. These responses are maintained by the Department of Justice Office of General Counsel and can be found on their website​.

 ​​

 

 

 

2017 findings and recommendations 


Inquest into the death of Charles Welsford SMITHERS

Decision of Deputy State Coroner O'Sullivan on 15 September 2017

Catchwords: CORONIAL LAW, cause and manner of death, sudden cardiac death


Inquest into the death of Lynne BARNETT

Decision of Deputy State Coroner Grahame on 14 September 2017

Catchwords: CORONIAL LAW, cause and manner of death


Inquest into the death of Bruce THOMAS

Decision of Deputy State Coroner O'Sullivan on 7 September 2017

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, natural causes.


Inquest into the death of David WOTHERSPOON

Decision of State Coroner Barnes on 31 August 2017

Catchwords: CORONIAL LAW, death in custody, mental health services and security in correctional centres, internal autopsies and external examinations for deaths in custody


Inquest into the death of Matthew LEVESON

Decision of Magistrate Truscott on 25 August 2017

Catchwords: CORONIAL LAW, section 61 certificate, discharge of subpoena for witness to give evidence


Inquest into the death of Joel MURPHY

Decision of Coroner Russell on 24 August 2017

Catchwords: CORONIAL LAW - suspension of inquest

 

Inquest into the disappearance and death of Esmeraldo San Juan

Decision of Deputy State Coroner Ryan on 22 August 2017

Catchwords:CORONIAL LAW – Missing person – rock fishing death – recommendations made in 2015 inquest.


Inquest into the death of Samuel SEETO

Decision of Deputy State Coroner O'Sullivan on 21 August 2017

Catchwords: CORONIAL LAW, myocarditis, syncope



Inquest into the death of Donald McKinnon

Decision of Deputy State Coroner Ryan on 21 August 2017

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, natural causes, adequacy of care and treatment received from Corrective Services and Justice Health.

 

Inquest into the death of MC

Decision of Deputy State Coroner Grahame on 17 August 2017

Catchwords: CORONIAL LAW, death in a police operation, police shooting, self-inflicted death


 

Inquest into the death of Alyce POLLETT

Decision of State Coroner Barnes on 15 August 2017

Catchwords: CORONIAL LAW, suspicious death, possible asphyxiation of pregnant woman, unascertained cause of death



Inquest into the disappearance and suspected death of Alan LY

Decision of Deputy State Coroner O'Sullivan on 8 August 2017

Catchwords: CORONIAL LAW, cause and manner of death, missing person



Inquest into the death of BJ

Decision of Deputy State Coroner Grahame on 1 August 2017

Catchwords: CORONIAL LAW, death in a police operation



Inquest into the death of Paigh BARTHOLOMEW

Decision of Deputy State Coroner Barry on 25 July 2017

Catchwords: CORONIAL LAW, death in custody, mixed drug toxicity, drugs illegally delivered to correctional centre


 

Inquest into the suspected death of James Arthur HENNEY

Decision of State Coroner Barnes on 13 July 2017

Catchwords: CORONIAL LAW, suspected death, failure to report to Coroner, open finding

 

 

Inquest into the death of Warren MAGUIRE

Decision of Deputy State Coroner Barry on 13 July 2017

Catchwords: CORONIAL LAW, critical incident Computer Aided Dispatch (CAD) Training, identification of incident categories

 

 

Inquest into the suspected death of missing person Benjamin STEPHENS

Decision of Deputy State Coroner Lee on 12 July 2017

Catchwords: CORONIAL LAW, missing person, whether now deceased, cause and manner of death

 

 

Inquest into the death of CCW

Decision of Deputy State Coroner Barry on 11 July 2017

Catchwords: CORONIAL LAW, suicide risk, observation levels

 

 

Inquest into the death of LP

Decision of Deputy State Coroner Barry on 11 July 2017

Catchwords: CORONIAL LAW, death in Police operation, third person intervention during negotiations

 

 

Inquest into the death of Benjamin GILLIGAN

Decision of Deputy State Coroner Grahame on 7 July 2017

 Catchwords: CORONIAL LAW, death in a police operation, flight from psychiatric care.

 

 

Inquest into the death of Kerry FORREST

Decision of Deputy State Coroner Lee on 6 July 2017

Catchwords: CORONIAL LAW, death in custody, natural cause, terminal illness.

 


Inquiry into explosion at 55 Surveyor St, Queanbeyan

Decision of Deputy State Coroner Antrum on 30 June 2017

 

 

Inquest into the death of David BROWNE

Decision of Deputy State Coroner O'Sullivan on 22 June 2017

Catchwords: CORONIAL LAW, cause and manner of death, combat sports, boxing.



Inquest into the death of Ian BAKER

Decision of Deputy State Coroner O'Sullivan on 19 June 2017

Catchwords: CORONIAL LAW, power boat racing, water ski racing, high speed on water racing, speed restrictions, emergency equipment, aquatic licences.



Inquest into the death of a person known as Paul LACHLAN

Decision of Deputy State Coroner Grahame on 19 June 2017

Catchwords: CORONIAL LAW, identity



Inquest into the death of Thangarajah SITHAMPARAPILLAI

Decision of Coroner Russell on 16 June 2017

Catchwords: CORONIAL LAW, missing person



Inquest into the death of Colin HAY

Decision of Deputy State Coroner Lee on 9 June 2017

Catchwords: CORONIAL LAW, death in custody, natural cause, terminal illness.



Inquest into the death of Ahlia RAFTERY

Decision of Deputy State Coroner Lee on 9 June 2017

Catchwords: CORONIAL LAW, self-inflicted death, adolescent mental health, psychiatric intensive care unit, Mater Mental Health Centre, transfer of care, patient observation levels, risk assessment, handover process, ISBAR, nurse-to-patient ratios, back-to-base pulse oximetry.



Inquest into the disappearance and suspected death of Katherine ACKLING-BRYEN

Decision of Deputy State Coroner Grahame on 9 June 2017

Catchwords: CORONIAL LAW, missing person, declaration of death.


Inquest into the death of Craig LEISHMAN

Decision of Deputy State Coroner O'Sullivan on 7 June 2017

Catchwords: CORONIAL LAW, cause and manner of death, chronic alcoholism, alcoholic ketoacidosis (AKA)



Inquest into the death of Helen Ashburn

Decision of Deputy State Coroner Grahame on 6 June 2017

Coronial Law; policy and procedures for identifying domestic violence in hospital emergency departments.

 

Inquest into the disappearance and suspected death of Cesar LLANTO and death of Hector COLLADO

Decision of Deputy State Coroner Freund on 31 May 2017

Catchwords: CORONIAL LAW, missing person, multiple deaths, foreign flagged marine vessel, interjurisdictional investigation.



Inquest into the deaths arising from the Lindt Cafe siege

Decision of State Coroner Barnes on 24 May 2017



Inquest into the death of Bruce Burrell

Decision of Deputy State Coroner Lee on 9 May 2017

Catchwords: CORONIAL LAW - death in custody, natural cause, terminal illness.

 

 

Inquest into the suspected death of Anthony FAHEY

Decision of Deputy State Coroner Lee on 27 April 2017

Catchwords: CORONIAL LAW - missing person, whether person now deceased, no jurisdiction.



Inquest into the death of Heidi COX

Decision of Deputy State Coroner Lee on 19 April 2017

Catchwords: CORONIAL LAW - manner of death, subdural haemorrhage, haematoma, bruising, domestic violence.



Inquest into the death of AR

Decision of Deputy State Coroner Ryan on 6 April 2017

Catchwords: CORONIAL LAW – cause and manner of death; death in residential care facility; drug toxicity (Fluvoxamine); SUDEP; adequacy of care and treatment.

 


 

Inquest into the death of Keith HOWLETT

Decision of Deputy State Coroner Grahame on 31 March 2017

Catchwords: CORONIAL LAW, death in custody, cancer treatment in a custodial setting, palliative care in a custodial setting.


 


 

Inquest into the death of John Inman BALE

Decision of Deputy State Coroner Grahame on 30 March 2017

Catchwords: CORONIAL LAW, death in a police operation, transfer and termination of a 000 call, self inflicted death.


 


 

Inquest into the death of Meaghan GARDNER

Decision of Deputy State Coroner O'Sullivan on 15 March 2017

Catchwords:  CORONIAL LAW, cause and manner of death.


 


 

Inquest into the death of Ronald BRIZZOLARA

Decision of Deputy State Coroner O'Sullivan on 17 March 2017

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, cell alarm failure, natural causes.


 


 

Inquest into the death of Bridgett CURRAH

Decision of Deputy State Coroner O'Sullivan on 16 March 2017

Catchwords: CORONIAL LAW, cause and manner of death, dehydration, cyanotic congenital heart disease (CCHD), gastro-oesophageal reflux disease (GORD), recording of clinical observations and review notes.


 


 

Inquest into the death of Brandoli Pou

Decision of Deputy State Coroner Ryan on 16 March 2017

Catchwords:  CORONIAL LAW- Cause and manner of death, severe chest injuries, industrial accident, struck by heavy lifting machinery ,whether employee adequately trained in operation of cranes, whether safe operating procedures adequate and complied with, recommendations. 

 

Inquest into the death of David Black

Decision of Deputy State Coroner Lee on 13 March 2017

Catchwords: CORONIAL LAW – aviation, non-destructive testing, eddy current inspection, magnetic particle inspection, M18 Dromader, airworthiness directive, CAR 2A approval, Australian Transport Safety Bureau (ATSB), Civil Aviation Safety Authority (CASA).

Inquest into the disappearance and suspected death of Joel SHEILES

Decision of Deputy State Coroner O'Sullivan on 8 March 2017

Catchwords: CORONIAL LAW, cause and manner of death, missing person.


 

Inquest into the death of Louis NAUMOVSKI

Decision of Deputy State Coroner O'Sullivan on 7 March 2017

Catchwords: CORONIAL LAW, cause and manner of death, unascertained.

 

Inquest into the death of Dennis CAVANAGH

Decision of Deputy State Coroner O'Sullivan on 2 March 2017

Catchwords: CORONIAL LAW, cause and manner of death, cause of death unascertained.


 


 

Inquest into the death of RC

Decision of Deputy State Coroner O'Sullivan on 28 February 2017

Catchwords: CORONIAL LAW, cause and manner of death, suicide risk assessment.


 


 

Inquest into the death of James Hughes

Decision of Deputy State Coroner O'Sullivan on 21 February 2017

Catchwords: CORONIAL LAW, cause and manner of death, motorcycle accident, pothole in road, Goulburn Mulwaree Council response to complaints about condition of road. 

 

Inquest into the death of Thanh PHAM

Decision of Deputy State Coroner Grahame on 3 February 2017

Catchwords: CORONIAL LAW, manner of death, karate, traumatic head injury.


  

Inquest into the disappearance and suspected death of Colin Campbell

Decision of Deputy State Coroner O'Sullivan on 18 January 2017

Catchwords: CORONIAL LAW, cause and manner of death, missing person


 
Inquest into the deaths of EG & JB

Decision of Deputy State Coroner Lee on 13 January 2017
Catchwords: CORONIAL LAW, homicide, suicide, electrocution, mandatory inquest.



2016 findings and recommendations


Inquest into the death of Shona Hookey

Decision of Deputy State Coroner Dillon on 22 December 2016

Catchwords: Cause and manner of death, hospital death, disabled patient unable to speak, undiagnosed twisted bowel, whether response at care facility was appropriate, whether response at hospital was appropriate, whether patient could have survived if response different, improvements to systems.


 

Inquest into the disappearance and suspected death of Suat Yildirimtekin

Decision of Deputy State Coroner Lee on 22 December 2016

Catchwords: Missing person, cause and manner of death, unsolved homicide.


Inquest into the death of Brendan Hickey

Decision of Deputy State Coroner O'Sullivan on 22 December 2016

Catchwords: CORONIAL LAW, cause and manner of death, drowning, risk assessments, Vivid 2014, Darling Harbour.

 

Inquest into the death of Kyran DAY

Decision of Deputy State Coroner O'Sullivan on 21 December 2016

Catchwords: CORONIAL LAW, paediatric training and assessment, children and infants with gastroenteritis - acute management guidelines, dehydration in children, between the flags charts, Newborn and Paediatric Emergency transport (NETS), ambulance, intussusception, REACH program.


 

Inquest into the death of George TRIANTAFILOPOULOS

Decision of Deputy State Coroner Grahame on 20 December 2016

Catchwords: CORONIAL LAW, fall, anticoagulation therapy and closed head injury.


 

Inquest into the death of Frederick PEISLEY

Decision of Deputy State Coroner O'Sullivan on 16 December 2016

Catchwords: CORONIAL LAW, community treatment orders, nursing home, electronic medical record keeping.


 

Inquest into the death of Blaine ROZS

Decision of Coroner Jerram on 13 December 2016

Catchwords: CORONIAL LAW, cause and manner of death, fall from tractor, traumatic asphyxia, recommendations for workplace safety.​​

 

Inquest into the death of Ezekiel HOWARD

Decision of Deputy State Coroner O'Sullivan on 8 December 2016

Catchwords: CORONIAL LAW, cause and manner of death, sudden unexplained death in epilepsy (SUDEP), sudden cardiac death (SCD), sudden unexplained death of a child, back-up of medical records.


 

Inquest into the death of Michael GAVANAS

Decision of Deputy State Coroner O'Sullivan on 7 December 2016

Catchwords: CORONIAL LAW, cause and manner of death, acute methamphetamine toxicity.


 

Inquest into the disappearance and suspected death of Gunawan PANDISAPUTRA

Decision of Deputy State Coroner Grahame on 5 December 2016

Catchwords: CORONIAL LAW, missing person, no jurisdiction.


 

Inquest into the deaths of Robert PASHKUSS and Stacey McMAUGH

Decision of Deputy State Coroner Dillon on 1 December 2016

Catchwords: CORONIAL LAW, cause and manner of death, homicide, drug-related deaths, person or persons responsible for death not identified.


 

Inquest into the Death of Beata Vandeville

Decision of Deputy State Coroner Lee on 24 November 2016

Catchwords: CORONIAL LAW – propofol, fentanyl, midazolam, restricted substances, anaesthetist, Royal Australian College of Obstetricians and Gynaecologists

 

Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS

Decision of Deputy State Coroner Barry on 22 November 2016

Catchwords: CORONIAL LAW, cause and manner of death, ingestion of methanol, distilling and sale of spirits, organising pneumonia, alcoholic liver disease.

 

Inquest into the death of JC

Decision of Deputy State Coroner O'Sullivan on 17 November 2016

Catchwords: CORONIAL LAW, cause and manner of death, death in police operation, self-inflicted gunshot wound, suicide, mandatory inquest.


 

Inquest into the death of AA​​

Decision of Deputy State Coroner Lee on 14 November 2016

Catchwords: CORONIAL LAW, self-immolation, suicide, police operation.


 

Inquest into the death of Hellen Marsh

Decision of Magistrate Beattie, Wollongong November 4 2016

Catchwords: CORONIAL LAW; surgery decisions; arterial injury; adequacy of anaesthesia record keeping.

 

Inquest into the Death of Phillip Hughes

Decision of State Coroner Barnes on 4 November 2016

Catchwords: CORONIAL LAW – violent and unnatural death; cricket match; head trauma; emergency response; protective equipment; review of rules

 


Inquest into the death of Michael JOHNSON

Decision of Deputy State Coroner O'Sullivan on 1 November 2016

Catchwords: CORONIAL LAW, cause and manner of death, person trapped under vehicle, traumatic asphyxia.

 

Inquest into the disappearance and suspected death of Gaida COOTE

Decision of Deputy State Coroner Grahame on 28 October 2016

Catchwords: CORONIAL LAW, missing person, search and rescue operation.



 

Inquest into the death of Audrey MacGREGOR

Decision of Deputy State Coroner Grahame on 26 October 2016

Catchwords: Coronial law, cause of death, hydromorphone overdose

 

Inquest into the death of Savvas Epsimos

Decision of Deputy State Coroner O'Sullivan on 20 October 2016

Catchwords: CORONIAL LAW – Cause and manner of death, Aged care facility, Falling out of bed.


 

Inquest into the disappearance and suspected death of Andrew Russell

Decision of Deputy State Coroner Grahame on 13 October 2016

Catchwords: Coronial Law - Missing person - Referrral to Unsolved Homicide Unit

 

Inquest into the death of Phillip HUGHES

Opening statement of Counsel Assisting​ on 10 October 2016

Before His Honour Magistrate Barnes, State Coroner

 

Inquest into the death of Terry Riordan

Decision of Deputy State Coroner Barry on 30 September 2016

Catchwords: CORONIAL LAW ; police investigation; concern for welfare; medical record keeping.


Inquest into the death of NA

Decision of Deputy State Coroner Grahame on 14 September 2016

Catchwords: CORONIAL LAW, home birth without medical assistance, manner and cause of death.


Inquest into the death of Rodney James BATES

Decision of Deputy State Coroner Grahame on 14 September 2016

Catchwords: CORONIAL LAW, cause and manner of death, death in custody

 

Inquest into the death of M 

Decision of Deputy State Coroner Lee on 12 September 2016

Catchwords: CORONIAL LAW, child death, out of home residential care, drug overdose, drug toxicity, care and protection.

 

Inquest into the death of Miriam MERTEN

Decision of Coroner Linden (Lismore Court) on the 7 September 2016

Catchwords: CORONIAL LAW, care and treatment, mental health unit at Lismore hospital, consideration of criminal charges.


Inquest into the death of Stacey Lee HUTCHINS

Decision of Deputy State Coroner MacMahon on 26 August 2016

Catchwords: CORONIAL LAW, resumption of inquest following suspension, cause and manner of death, involvement of NSWPF in circumstances of death.

 

Inquest into the disappearance and suspected death of Cheryl ARDLER

Decision of Deputy State Coroner O'Sullivan on 19 August 2016

Catchwords: CORONIAL LAW, missing person, domestic violence, section 61 Coroners Act 2009

 

Inquest into the death of Vasko Boskovski

Decision of Coroner Jerram on 17 August 2016

Catchwords: CORONIAL LAW, unsolved homicide

 

Inquest into the death of Helen Dawson (also known as Marcia Helen Key)

Decision of Deputy State Coroner O'Sullivan on 12 August 2016

Catchwords: CORONIAL LAW, cause and manner of death, homicide, sections 78 and 79 Coroners Act 2009

 

Inquest into the deaths of Mr TK and Mrs TK

Decision of Deputy State Coroner Lee on 11 August 2016

Catchwords: CORONIAL LAW, homicide, suicide, madatory inquest

 

Inquest into the death of Afif Fakhouri

Decision of Deputy State Coroner Barry on 11 August 2016

​Catchwords: CORONIAL LAW – Excited Delirium, Positional Asphyxia, Restraint, Methylamphetamine Toxicity.

 

Decision of Coroner Jerram on 9 August 2016

Catchwords: CORONIAL LAW, missing persons, referral to unsolved homicide team.


 

Inquest into the death of Robert Taylor

Decision of Deputy State Coroner Grahame on 5 August 2016

Catchwords:  Coronial Law- Undetermined cause of death.

 

Inquest into the deaths of Benjamin Green and William Markee​​

Decision of Deputy State Coroner Grahame on 19 July 2016

Catchwords: CORONIAL LAW, manner of death, homicide, suicide, impact of untreated mental health issues.

DSC Grahame has ordered full publication of these Findings in accordance with s75(5) of the NSW Coroners Act 2009.


 
 
Decision of Magistrate Day on 15 July 2016 at Wyong Local Court
Catchwords: CORONIAL LAW, manner of death, deliberate act.
Magistrate Day has ordered full publication of these Findings in accordance with s75(5) of the NSW Coroners Act 2009.


 

Decision of Deputy State Coroner O'Sullivan on 15 July 2016

Catchwords: CORONIAL LAW – cause and manner of death, death in custody, natural causes​.

 

Inquest into the death of Sheila Drysdale

Decision of Deputy State Coroner Dillon on 15 July 2016

Catchwords: CORONERS, cause and manner of death, surgical case, “experimental” therapy for dementia, whether appropriate to perform unproven stem-cell procedure, whether informed consent given, whether patient properly prepared for procedure, surgical mishap in procedure, flaws in post-operative management of patient.

 

Inquest into the death of John McFerrier

Decision of Deputy State Coroner O'Sullivan on 14 July 2016

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, death in Villawood Immigration Detention Centre, natural causes.

 

Inquest into the death of Matthew Mitchell

Decision of Deputy State Coroner Barry on 12 July 2016

Catchwords: CORONIAL LAW – Blunt Force Head Injury , Motor vehicle collision, unknown Driver.

Inquest into the disappearance and suspected death of AK

​Decision of Deputy State Coroner Grahame on 5 July 2016

Catchwords: CORONIAL LAW, missing person.​


Inquest into the disappearance and suspected death of Alice Treverrow

Decision of Deputy State Coroner Barry on 1 July 2016

Catchwords: CORONIAL LAW, missing person, cause and manner of death.


Inquest into the death of Jason BRITTEN

Decision of Deputy State Coroner Grahame on 5 July 2016

Catchwords: CORONIAL LAW, cause of death.

 

Inquest into the death of NP and EP

Decision of Deputy State Coroner Lee on 30 June 2016

Catchwords: CORONIAL LAW, homicide, suicide, mandatory inquest.


 

Inquest into the death of Matthew DONNELLY

Decision of Deputy State Coroner Dillon on 23 June 2016

Catchwords: CORONIAL LAW, cause and manner of death, motor vehicle accident, trailer towed by arge vehicle unstable due to loading, whether P2 drivers of large vehicles should be supervised for a period, whether changes ought to be made to licensing testing requirements, whether P2 drivers of large vehicles ought to be permitted to tow trailors.


 

Inquest into the death of William MacDONALD

Decision of Deputy State Coroner O'Sullivan on 9 June 2016

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, aged care in custody, natural causes, resuscitation plans in end of life decisions.

 

Inquest into the deaths of ​Ranjit Singh and Sandeep Thind

Decision of Deputy State Coroner Dillon on 10 June 2016

Catchwords: CORONIAL LAW, death in cu​stody, homicide/suicide, remanded prisoner suicide following homicide of wife, suicide risk assessment, placement in "one-out" cell, CCTV equipment failure.​

 

Inquest into the death of Narayana SIMPSON

Decision of Deputy State Coroner Lee on 23 May 2016

Catchwords: CORONIAL LAW, death in police operation, police pursuit, NSW Police Force Safe Driving Policy, Critical Incident Guidelines


Inquest into the death of the Unknown human male person whose torso was found on the 27 January 2012 at Kyeemagh Beach in Botany Bay

Decision of Deputy State Coroner Lee on 19 May 2016

Catchwords: CORONIAL LAW, cause and manner of death, unsolved homicide.


Inquest into the deaths arising from the MH-17 aircraft crash - Carol Anne Clancy, Michael Martin Clancy, Gabriele Lauschet, Jack Samuel O’Brien, Victor Oreshkin and Mary Philomene Tiernan.

​Decision of State Coroner Barnes on 17 May 2016

Catchwords: CORONIAL LAW, manner and cause of death, aviation disaster. 

 

 

Inquest into the disappearance and suspected death of Eric WARBURTON

Decision of Deputy State Coroner Grahame on 10 May 2016

Catchwords: CORONIAL LAW, missing person.

 

​​Inquest into the death of Idris GRIFFITHS

Decision of Deputy State Coroner Lee on 29 April 2016

Catchwords: CORONIAL LAW, death in custody, natural causes, care and treatment.

 

Inquest into the death of Bradley Miller

Decision of Deputy State Coroner Barry on 19 April 2016

Catchwords: CORONIAL LAW, adequacy of autopsy, Coronial Medical Officer, adequacy of Police response.

 

Inquest into the death of Ida ROMEO

Decision of Deputy State Coroner Lee on 8 April 2016

Catchwords: CORONIAL LAW, cause and manner of death, Liverpool hospital, cardiology, constrictive pericarditis, pressure wire, mechanical aortic valve, consent.

 

Inquest into the death of Paul SMITH

Decision of Deputy State Coroner Dillon on 8 April 2016

Catchwords: CORONIAL LAW, cause and manner of death, Industrial accident, worker trapped in stormwater drain, whether risk adequately assessed, whether policies and procedures appropriate, whether policies and procedures complied with, fluid dynamics of stormwater and underestimation of risk, whether rescue possible, changes to infrastructure and policy consequent to fatal accident.


 

Inquest into the disappearance and suspected death of Jason DAVIES

Decision of Deputy State Coroner Lee on 5 April 2016

Catchwords: CORONIAL LAW, missing person, cause and manner of death.

 

Inquest into the death of Patricia NORTHCOTE

Decision of Deputy State Coroner O'Sullivan on 5 April 2016

Catchwords: CORONIAL LAW, pressure sores, aged care.

 

Inquest into the death of James Leslie STOCKS

Decision of Deputy State Coroner Grahame on 30 March 2016

Catchwords: CORONIAL LAW, manner of death

 

Inquest into the disappearance and suspected death of Peter Millett

Decision of Deputy State Coroner Barry on 24 March 2016

Catchwords: CORONIAL LAW, missing person

 

Inquest into the disappearance and suspected death of Pideuk JUNG

Decision of Deputy State Coroner Grahame on 17 March 2016

Catchwords: CORONIAL LAW, missing person, Missing Persons Standard Operating Procedures (SOPs)

 

Inquest into the death of Karl Guy MEYERS

Decision of Deputy State Coroner Grahame on 17 March 2016

Catchwords: CORONIAL LAW, cause of death, removal of nasogastric tube(NGT)

 

Inquest into the death of Tommy NGO

Decision of Deputy State Coroner Grahame on 15 March 2016

Catchwords: CORONIAL LAW, manner of death, Chinese lion dancing.


 

Inquest into the death of Michael Nolan

Decision of State Coroner Barnes on 11 March  2016

Catchwords: CORONIAL LAW - death in custody, prison mental health; self-harm risk assessment.

 

Inquest into the death of Christopher Luke O'SULLIVAN

Decision of Deputy State Coroner MacMahon on 11 March 2016

Catchwords: CORONIAL LAW - mandatory inquest, manner of death, non-accidental injuries, standard of proof.

 

Inquest into the death of Else COGHILL

Decision of Deputy State Coroner Dillon on 11 March 2016

Catchwords: CORONIAL LAW - cause and manner of death, death of infant, whether antenatal arrangements were appropriate, whether augmentation of labour was appropriate, whether an operating theatre should have been made available during labour, whether a paediatrician should have been present at birth, whether immediate postnatal care was appropriate

 

Inquest into the death of To Minh TU

Decision of Deputy State Coroner O'Sullivan on 9 March 2016

Catchwords: CORONIAL LAW - unsolved homicide

 

Inquest into the death of Allen BURKE

Decision of Deputy State Coroner Lee on 8 March 2016

Catchwords: CORONIAL LAW, death in custody, natural causes, care and treatment.

 

Inquest into the death of David FLEMING

Decision of Deputy State Coroner Lee on 8 March 2016

Catchwords: CORONIAL LAW, death in custody, natural causes, care and treatment.

 

Inquest into the death of Matthew Richell

Decision of State Coroner Barnes on 4th March 2016

Catchwords: CORONIAL LAW - manner and cause of death; beach drowning; lifeguard services.

 

Inquest into the death of Rhyan Dickson

Decision of Magistrate Truscott on 26th February 2016

Catchwords: CORONIAL LAW - Cause and manner of death.

 

Inquest into the disappearance and suspected death of KH

Decision of State Coroner Barnes on 19 February 2016

Catchwords: CORONIAL LAW – Cause and manner of death, suspected death; intentionally self-inflicted; cruise ship.

 

Inquest into the death of unidentified baby, "Lily Grace"

Decision of Deputy State Coroner Dillon on 10 February 2016

Catchwords: CORONIAL LAW - whether child stillborn, open findings in respect of identity, date and place of death, cause and manner of death, recommendations: "baby boxes", "safe haven", laws for protection of abandoned babies.

 

Inquest into the death of SS

Decision of Deputy State Coroner Lee on 5 February 2016

Catchwords: CORONIAL LAW, care and treatment at Gosford Hospital, communication between primary carer and physicians

 

Inquest into the death of Jimmy James

Decision of Deputy State Coroner Truscott on 29 January 2016

Catchwords: CORONIAL LAW, cause and manner of death, hospital, pathway medicine, protocol, "Between the Flags", record keeping, hospital review.


 

Inquiry into Multiple Fires - 10 Railway St Lidcombe, 20 Bennelong Crescent Bellevue Hill, 38-42 Seville St Fairfield East

Decision of  State Coroner Barnes on 18 January 2016

Catchwords: CORONIAL LAW - fire inquiry; general inquiry; multiple fires; similarity of mechanism; motive.  


 

Inquest into the death of Leonie Philpott

Decision of State Coroner Barnes on 20 January 2016

Catchwords: CORONIAL LAW – natural causes, unascertained.


 

​​​​

2015 findings and recommendations

​​

Inquest into the death of Chayce KELLY

Decision of Deputy State Coroner Truscott on 30 December 2015

Catchwords: CORONIAL LAW - cause and manner of death, drowning, recommentations.


 

Inquest into the death of Officer A

Decision of Deputy State Coroner Dillon on 18 December 2015

Catchwords: CORONIAL LAW - cause and manner of death, self-inflicted death, police officer on duty, nature and cause of mental condition, whether management and treatment of psychological injury appropriate, whether decision to move officer managed appropriately, whether relationships between officer and other officers contributed to her death, whether search for officer conducted appropriately.

 

Inquest into the death of GM

Decision of Deputy State Coroner O'Sullivan on 15 December 2015

Catchwords: CORONIAL LAW - cause and manner of death, suicide, death in a police operation, police unable to prevent death, the Gap park.

 

Inquiry into the fire at 3/40 Bowman Street, Richmond

Decision of Deputy State Coroner O'Sullivan on 15 December 2015

Catchwords: CORONIAL LAW - fire

 

Inquest into the death of Adam Southwick

Decision of Deputy State Coroner Forbes on 3rd December 2015

Catchwords: CORONIAL LAW, death in custody, death in police station charge dock, positional asphyxia, methylamphetamine intoxication, implementation of police policy and procedure.

 

Inquest into the death of Jessica Martin

Decision of Deputy State Coroner Forbes on 2nd December 2015

Catchwords: CORONIAL LAW, cause and manner of death, undiagnosed Addison's Disease, care and treatment.


 

Inquest into the death of Peter Domachuk

Decision of Deputy State Coroner Forbes on 2nd December 2015

Catchwords: CORONIAL LAW, cause and manner of death, undiagnosed Addison's Disease, discharge from hospital.

 

Inquest into the death of Madeleine Duffy

Decision of Deputy State Coroner Freund on 27th November 2015

Catchwords: CORONIAL LAW, Cerebral Palsy, Respite Care, Care and Treatment.
 


Inquest into the deaths of Donald EVELEIGH, Angela STACKMAN, 'FW', 'ML', Anthony WALDRON, Colin REID, Bradley JACKSON, Robert BEAMISH and 'LE' who died as a result of a Quad bike accident

Decision of Deputy State Coroner Freund on 26 November 2015

Catchwords: CORONIAL LAW, cause and manner of death, quad bike accident, public health and safety, Australian safety standards, training and licensing, crush protection devices, recommendation.

 

 

Inquest into the death of ​​Matthew Lewis

Decision of Deputy State Coroner Freund on 2 September 2015

Catchwords: CORONIAL LAW, cause and manner of death, vehicle modified​ for hunting, use of firearms without a licence.


 

Inquest into the death of Dylan MAHER

Decision of Deputy State Coroner Grahame on 23 November 2015

Catchwords: CORONIAL LAW, police pursuit, safe driving policy

 

 

Inquest into the death of Bridget WRIGHT

Decision of Deputy State Coroner Barry on 20 November 2015

Catchwords:  CORONIAL LAW, cause and manner of death, tree management in schools, Department of Education guidelines, multiple injuries.

 

 

Inquest into the death of Tyrone Slemnik​​

Decision of State Coroner Michael Barnes on 19 November 2015

Catchwords: CORONIAL LAW, cause and manner of death, outlaw motorcycle gangs.

 

Inquest into the death of Housam ISMAIL

Decision of Deputy State Coroner Truscott on 18 November 2015

Catchwords:  CORONIAL LAW, cause and manner of death, police operation.

 

Inquest into the death of Ivy Dwyer

Decision of Deputy State Coroner Forbes on 16 November 2015

Catchwords: CORONIAL LAW, cause and manner of death, care and treatment in remote area, illness not responding to treatment, myocarditis

 

Inquest into the death of "W"

Decision of Deputy State Coroner Freund on 11 November 2015

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, recommendations.

 

 

Inquest into the death of person known as "Andy"

Decision of Deputy State Coroner Truscott on 11 November 2015

Catchwords: CORONIAL LAW, identify, cause of death

 

Inquest into the death of Noreen PEACOCK

Decision of Deputy State Coroner Freund on 29 October 2015

Catchwords: CORONIAL LAW, cause and manner of death

 

Inquest into the death of Michael NELSON

Decision of Deputy State Coroner Freund on 28 October 2015

Catchwords: CORONIAL LAW - cause and manner of death

 

Inquest into the death of Scott Clements

Decision of Deputy State Coroner Grahame on 23 October 2015

Catchwords: CORONIAL LAW - cause and manner of death

 

Inquest into the death of Mary-Anne TURNER

Decision of Deputy State Coroner Grahame on 23 October 2015

Catchwords: CORONIAL LAW - cause and manner of death

 
Inquest into the death of Christine Drinnan
 
Decision by Deputy State Coroner Forbes on 23 October 2015
 
Catchwords: CORONIAL LAW-Cause and manner of death- Drug toxicity-Prescription drugs-care and treatment-Whether doctors appropriately prescribed
 

Inquest into the death of Mark LUCIC

Decision of Deputy State Coroner Grahame on 15 October 2015

Catchwords: CORONIAL LAW - cause and manner of death, ambulance delay, accidental overdose.

 

 

Inquest into the death of Kelvin Gardoll

Decision of Deputy State Coroner Forbes on 19 October 2015

Catchwords: CORONIAL LAW-Death in custody-Cause and manner of death

 

Inquest into the deaths of Nicholas KARAYIANNIS and Tien TRAN

Decision of Deputy State Coroner Dillon on 13 October 2015

Catchwords: CORONERS, cause and manner of death, deaths in custody, Homicide/suicide of cellmates, Whether mental health assessment reasonable, Whether prisoners safe at night, Whether remand prisoners sufficiently informed of self-harm protocols, whether "culture of silence" among prisoners jeopardising prisoner safety, whether "knock-up" alarm system sufficient protection for prisoner.

 

Inquest into the deaths of Geoffrey Francis HUNT, Kim Jeannine HUNT, Fletcher Austin HUNT, Mia Isobel HUNT and Phoebe Amelia HUNT

Decision of State Coroner Barnes on 9 October 2015

Catchwords: CORONIAL LAW, manner and cause of death, filicide, impacts of mental illness and acquired brain injury, family.

​​ 

Inquiry into the fire at Wambelong Camp Ground, Warrumbungles National Park, New South Wales

Decision of Deputy State Coroner Dillon on 28 September 2015

Catchwords: CORONERS – General fire inquiry – Unprecedented catastrophic wildfire in Warrumbungles National Park – Cause and origin of fire – Whether deliberately lit – Whether hazard reduction plans and operations appropriate – Whether fire appropriately classified at relevant times – Problems with accuracy of fire prediction models – Fire behaviour in extreme conditions – Whether fire management was reasonable in circumstances – Whether back burning operations were appropriate – Whether emergency warnings to local area were timely – Lessons learned

 

 

Inquest into the death of Kerryn FOALE

Decision of Deputy State Coroner Dillon on 26 September 2015

Catchwords: CORONIAL LAW, cause and manner of death, ventricular fibrillation in a patient with implanted defibrillator, why defibrillator failed, whether manufacturer gave appropriate warnings of the possibility of the failure of the device, whether the technical fault in the device has been addressed.

 

Inquest into the death of Aoni PENG

Decision of State Coroner Barnes on 23 September 2015

Catchwords: CORONIAL LAW, manner and cause of death, motor vehicle running down case, referral to DPP.

 

Inquest into the death of Willam CREWS

Decision of State Coroner Barnes on 21 September 2015

Catchwords: CORONIAL LAW, death in a police operation, execution of search warrants, risk assessment, protective equipment, supervision by police officers, police training.

 

Inquest into the death of Connie ZHANG and inquiry into the fire at Unit 53, 4 West Terrace Bankstown

Decision of Deputy State Coroner Dillon on 18 September 2015

Catchwords: CORONERS – Inquest -- Cause and manner of death – Catastrophic fire in residential tower -- Fall from height to escape burning building

CORONERS – Fire inquiry – Cause and origin of fire in residential apartment tower – Why fire escalated so quickly – Whether building complied with fire safety standards -- Whether fire safety standards adequately regulated and enforced –

 

Inquest into the death of Gary ALLIBON

Decision of Deputy State Coroner Barry on 11 September 2015

Catchwords: CORONIAL LAW, cause and manner of death, shot during armed robbery, reward, referred to unsolved homicide unit.

 

Inquest into the death of Ryan LEO

Decision of Deputy State Coroner Truscott on 4 September 2015

Catchwords: CORONIAL LAW, cause and manner of death, road safety education, supervision of child crossing road, recommendations.

 

Inquiry into the fire at UTS on 27 November 2012

Decision of Coroner Barry on 25 August 2015

Catchwords: CORONIAL LAW, cause and origin of fire, public safety, recommendations.

 

Inquest into the death of Leif James

Decision of Deputy State Coroner Forbes on the 28 August 2015

Catchwords: CORONIAL LAW - Death in course of police operation-police pursuit-New South Wales Police Safe Driving Policy-critical incident guidelines

 

Inquiry into the fire at 5/15 Percy Street, Auburn

Decision of Deputy State Coroner Truscott on 19 August 2015

Catchwords: CORONIAL LAW - suspicious fire, insurance.

 

Inquest into the death of Aaron MaGarry

Decision of Deputy State Coroner Dillon on 18 August 2015

Catchwords: CORONIAL LAW – Cause and manner of death, Death in Police Operation, Drive in manner danger, Police Pursuit

 

Inquest into the death of Manjit SINGH

Decision of Deputy State Coroner Dillon on 17 August 2015

Catchwords: CORONIAL LAW - cause and manner of death, complications following removal of lung destroyed by active tuberculosis, 457 visa holder, Health undertakings by visa holders, medical screening of immigrants and visa holders with tuberculosis by NSW Health, care and treatment at Royal North Shore Hospital, exemplary conduct by clinicians and nurses.

 

Inquest into the death of Kathryn Anne SHEPPARD

Decision of Deputy State Coroner MacMahon on 14 August 2015

Catchwords: CORONIAL LAW, death following aircraft engine failure, section 81(1) findings, engagement of families of deceased with regulator, Recommendations made in accordance with section 82.

 

Inquest into the death of Andrew Alan Thomas WILSON

Decision of Deputy State Coroner MacMahon on 14 August 2015

Catchwords: CORONIAL LAW, death following aircraft engine failure, section 81(1) findings, engagement of families of deceased with regulator, Recommendations made in accordance with section 82.

 

Inquest into the death of AJ (name redacted)

Decision of Deputy State Coroner Forbes on 11 August 2015

Catchwords: CORONIAL LAW-Cause and manner of death-death in custody-recommendations-inmates referred for mental health review-inmates who fail to attend for antipsychotic medication

 

Inquest into the death of AC (name redacted)

Decision of Deputy State Coroner Dillon on 6 August 2015

Catchwords: CORONIAL LAW, cause and manner of death, death in a police operation, electrocution and multiple injuries caused by fall from power transmission tower.

 

Inquest into the death of David Luc MONLUN

Decision of Deputy State Coroner Freund on 4 August 2015

Catchwords: CORONIAL LAW, cause and manner of death, suspicious death, GHB, methyl-amphetamine, multi drug toxicity.

 

Inquest into the death of Daniel VELLA

Decision of Coroner Grahame on 3 August 2015

Catchwords: CORONIAL LAW, unsolved homicide

 

Inquest into the death of Phillip Buckley

Decision of Deputy State Coroner Forbes on 30 July 2015

Catchwords: CORONIAL LAW-Manner of death-prescription drug overdose-prescribing practices-recommendation-referral to HCCC

 

Inquest into the death of Farin DALEY

Decision of Deputy State Coroner Truscott on 27 July 2015

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, heart condition.

 

Inquest into the death of Lynette Maree YOUNG

Decision of Coroner Barry on 27 July 2015

Catchwords: CORONIAL LAW, care and treatment, inadequate handover, failure to recognise deteriorating condition and failure to respond, recommendations.

 

Inquest into the disappearance and suspected death of Judith YOUNG

Decision of Deputy State Coroner Freund on 23 July 2015

Catchwords: CORONIAL LAW, missing person, suspicious death.

 

Inquest into the death of AB

Decision of Deputy State Coroner MacMahon on 20 July 2015

Catchwords: CORONIAL LAW, death in custody, mandatory inquest, self-inflicted death with intention to end life, section 75(5) considerations.

 

Inquest into the death of SW

Decision of State Coroner Barnes on 15 July 2015

Catchwords: CORONIAL LAW, cause and manner of death, death in custody, intentionally self-inflicted, assessment of self-harm risk.

 

Inquest into the death of Jesse SMITH

Decision of Deputy State Coroner MacMahon on 15 July 2015

Catchwords: CORONIAL LAW, section 81(1) findings, section 78(1)(b), motor vehicle collision, identity of driver.

 

Inquest into the death of DA

Decision of Coroner Barry on the 14 July 2015

Catchwords:  CORONIAL LAW, self inflicted death.

 

Inquest into the death of Tyrone Gilks

Decision of State Coroner Barnes on the 10 July 2015

CORONIAL LAW – Cause and manner of death; motorcycle long distance jumping; risk management; responsibilities of land-holder, local authority; NSW Sport and Recreation

 

Inquest into the deaths of Myassar Ayoub, Donald White, Zheng Wang, Sung Su Cho, Greg Walter Reardon, Huiqing Hua, Ding Ding Zhang, Young Whan Kim & Jesse Jack Howes (Rock Fishing related deaths)

Decision of Deputy State Coroner Forbes on the 02 July 2015

CORONIAL LAW-Rock fishing deaths –Recommendations-Mandatory life-jackets

 

Inquest into the death of N

Decision of Coroner Barry on the 02 July 2015

CORONIAL LAW - cause and manner of death, suicide

 

Inquest into the disappearance and suspected deaths of Paul ROSSINGTON and Kristen SCHRODER

Decision of Deputy State Coroner Dillon on 30 June 2015

Catchwords: CORONIAL LAW, suspected deaths of missing persons, whether missing persons have died, cause and manner of deaths, undetected disappearance overboard from cruise ship, whether "Man Overboard" systems can be improved.

 

Inquest into the death of Jason William REA

Decision of Deputy State Coroner MacMahon on 26 June 2015

Catchwords: CORONIAL LAW, cause of death, death in circumstances of restraint, death arising out of, or in the course of, a police operation, effects of methylamphetamine.

 

Inquest into the disappearance and suspected death of Prabhdeep SRAWN

Decision of Coroner Grahame on 26 June 2015

Catchwords: CORONIAL LAW, missing person, search and rescue operation.

 

Inquest into the death of Tony BUGEJA

Decision of Deputy State Coroner Dillon on 26 June 2015

Catchwords: CORONIAL LAW - anaphylactic shock due to wasp sting, whether response time of ambulance affected outcome, allocation of ambulances, whether expired Epipen affected outcome, Ambulance policy and training concerning management of aggressive animals barring access to patient.

 

Inquest into the death of Giovanni TRIPODI

Decision of State Coroner Barnes on 24 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, adequacy of hospital care.

 

Inquest into the death of Vijay SINGH

Decision of Deputy State Coroner Forbes on 19 June 2015

Catchwords: CORONIAL LAW- cause and manner of death, death in workplace, death in course of police operation

 

Inquest into the death of Matthew THOMAS

Decision of Deputy State Coroner Forbes on 19 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, homicide.

 

Inquest into the death of Peter JUNGHANS

Decision of Deputy State Coroner Forbes on 19 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, self-inflicted.


 

Inquest into the death of Tremaine GATT

Decision of Coroner Barry on 18 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, manner of driving, supervision of child, multiple injuries due to motor vehicle collision.

 

Inquest into the death of AB

Decision of Deputy State Coroner Forbes on 16 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, death in custody, suicide.

 

Inquest into the death of Sean WAYGOOD

Decision of State Coroner Barnes on 16 June 2015

Catchwords: CORONIAL LAW - cause and manner of death, death in custody, standard of health care to maximum security prisoner.

 

Inquest into the death of Laurence Paul LANDER

Decision of Deputy State Coroner Freund on 10 June 2015

CORONIAL LAW – Missing Person; Cause and Manner of Death

 

Inquest into the death of Gabriele HANNEMANN

Decision of Coroner Grahame on 10 June 2015

Coronial Law-Cause of death

 

Inquest into the disappearance and suspected deaths of Gheorghe RADU and Iudit SIMIONESCU

Decision of State Coroner Barnes on 9 June 2015

Catchwords: CORONIAL LAW, missing persons

 

Inquest into the death of Trent LENTHALL

Decision of Deputy State Coroner Forbes on 3 June 2015

Catchwords: CORONIAL LAW, death in course of police operation, cause and manner of death, NSW police safe driving policy.

 

Inquest into the death of AB

Decision of Deputy State Coroner Forbes on 22 May 2015

Catchwords: CORONIAL LAW, death in police operation, police negotiations, transfer from corrective services to immigration detention.

 

Inquest into the death of Skye SASSINE

Decision of Deputy State Coroner MacMahon on 15 May 2015

Catchwords: CORONIAL LAW, mandatory inquest, death in a police operation, suspension of inquest, resumption of inquest following suspension, police pursuit, conduct of police during pursuit.

 

Inquest into the death of John Vincent CREAN

Decision of Coroner Grahame on 12 May 2015

Catchwords: CORONIAL LAW, missing person, procedure.

 

Inquest into the disappearance and suspected death of Ninus Pedro Paul SCOGNAMIGLIO

Decision of Deputy State Coroner MacMahon on 13 May 2015

Catchwords: CORONIAL LAW, missing person suspected of being deceased. 

 

Inquest into the disappearance and suspected death of John Ewen SCHRECK (aka John Charles STEWART)

Decision of Deputy State Coroner MacMahon on 20 April 2015

Catchwords: CORONIAL LAW, missing person suspected deceased, open findings made following inquest, fresh inquest directed on discovery of new evidence, findings made in substitution for those made at previous inquest.

 

Inquest into the death of William James ROBSON-PEARCE

Decision of Deputy State Coroner MacMahon on 14 April 2015

Catchwords: CORONIAL LAW, mandatory inquest, death in police operation, police pursuit, discretion to commence pursuit, pursuit of speeding motorcyclist, compliance with safe driving policy, recommendations.

 

Inquest into the death of SR

Decision of Deputy State Coroner Dillon on 2 April 2015

Catchwords: CORONIAL LAW, death in police operation, mandatory inquest, cause and manner of death, self-inflicted harm, fall onto railway car from bridge, Emergency electrical power stoppage by Sydney Trains, whether process efficient, performance by Sydney Trains staff, performance by NSW police officers.

 

Inquest into the disappearance and suspected death of Marion REES

Decision of Deputy State Coroner Freund on 1 April 2015

Catchwords: CORONIAL LAW, missing person, no jurisdiction.

 

Inquest into the death of Sebastien YEOMANS

Decision of Coroner Stafford on 1 April 2015

Catchwords: CORONIAL LAW, cause and manner of death, swimming pool regulations, pool not fenced, consideration of recommendations.

 

Inquiry into the fire at Sydney Aquatic Centre 13 October 2013

Decision of Coroner Barry on 23 March 2015

Catchwords: CORONIAL LAW, fire at Sydney Olympic Park (SOP), fire hydrants and signage, vegetation, extreme weather conditions.

 

Inquest into the death of John GIBSON

Decision of Deputy State Coroner Truscott on 16 March 2015

Catchwords: CORONIAL LAW, cause and manner of death.

 

Inquest into the death of Robert Gordon BRITTEN

Decision of Deputy State Coroner Truscott on 13 March 2015

Catchwords: CORONIAL LAW, cause and manner of death, section 27 inquest required, section 23 whether "lawful custody" includes Forensic Patients under the Mental Health (Forensic Provisions) Act 1990

 

Inquest into the deaths and fire at the Quakers Hills Nursing Home, Hambledon Road, Quakers Hill

Decision of Deputy State Coroner Dillon on 9 March 2015

Catchwords: CORONIAL LAW, joint inquests and fire inquiry, multiple deaths by fire and smoke inhalation, deliberately lit fire in nursing home, drug-dependent nurse stealing drugs, Lights fire to destroy evidence, How nurse employed, whether nurse should have been suspended before fire, whether fire safety standards met, whether design standards sufficient, response and performance by fire fighters, heroism of fire fighters, nursing staff & police officers, lessons learned, recommendations.

 

Inquest into the death of Andrew HABIB

Decision of Deputy State Coroner Dillon on 6 March 2015

Catchwords: CORONIAL LAW - cause and manner of death, hypertrophic cardiomyopathy, sudden death while participating in martial arts, whether fit to participate, whether subjected to choke hold, whether choke hold caused or contributed to sudden death, Code of practice, Recommendation for guideline for pre-exercise risk assessment and management.

 

Inquest into the death of Jake Robert INNES

Decision of Deputy State Coroner Dillon on 27 February 2015

Catchwords: CORONIAL LAW - death in the course of a police operation, police attempt to intercept speeding vehicle. vehicle fails to stop or slow when directed, driver loses control of vehicle, whether police engaged in high speed pursuit under safe Driving Policy, whether deceased was driver or passenger?, Coroners commendation of police for rescue effort after crash

 

Inquest into the death of Jean Vincent GOVINDEN

Decision of Deputy State Coroner MacMahon on 25 February 2015

Catchwords: CORONIAL LAW - suicide, publication of findings, recommendations.

 

Inquiry into the fire at 1 Bankshill Street, Carlingford

Decision of Deputy State Coroner MacMahon on 25 February 2015

Catchwords: CORONIAL LAW - fire of motor vehicle, link with death of Jean Govinden above

 

Inquest into the disappearance and suspected death of Margery Joyce TAYLOR

Decision of State Coroner Barnes on 20 February 2015

Catchwords: CORONIAL LAW - missing person, cause and manner of death

 

Inquest into the death of Neal Richardson

Decision of Deputy State Coroner Truscott on 17 February 2015

Catchwords: CORONIAL LAW - Natural death of person in custody

 

Inquest into the death of Baby RD

Decision of Deputy State Coroner Truscott on the 13 February 2015

Catchwords: CORONIAL LAW - Shaken Baby death-Criminal liability of carers in non-accidental death of child- Mandatory Reporters reports to FaCS Helpline and Reports to the police- automatic police dispatch with ambulance call out where child requires resuscitation

 

Inquest into the death of Annalies Malm

Decision of Deputy State Coroner Freund on the 3 February 2015

Catchword: CORONIAL LAW - natural cause death

 

Inquest into the death of Alec Samuel MEIKLE

Decision of Deputy State Coroner MacMahon on the 30 January 2015

Catchwords: CORONIAL LAW - suicide, question of location of cause of death, lack of jurisdiction.

 

Inquest into the death of FG

Decision of State Coroner Barnes on 23 January 2015

Catchwords: CORONIAL LAW - Railway overrun, responding to trespassers in the rail corridor

 

Inquest into the death of XY

Decision of Deputy State Coroner Freund on the 23 January 2015

Catchwords: CORONIAL LAW - suicide – adolescent mental health, expert evidence, application of section 20R of the Health Administration Act 1982 – meaning of “proceedings”

 

Inquest into the Death of James Ciappara

Decision of Deputy State Coroner MacMahon on 16 January 2015

Catchwords: CORONIAL LAW – Death in police operation, reason for mandatory inquest, NSW Police Force - Safe Driver Policy, dangerous products, recommendation for change of Australian Consumer Law to ban dangerous product

 

Inquest into the death of Stuart Michael Butler

Decision of State Coroner Barnes on 07 January 2015

Catchwords: CORONIAL LAW - Coroners court; missing person;presumed drowning;surf safety.

 

2014 finding​s and recommendations

 

Inquest into the death of Margaret Elizabeth HILLS

Decision of Deputy State Coroner MacMahon on 22 December 2014

Catchwords: CORONIAL LAW - person missing presumed deceased, person charged with indictable offence, suspended inquest, resumed inquest, standard of proof, self-inflicted death.

 

Inquest into the death of JX

Decision of State Coroner Barnes on the 19 December 2014

Catchwords: CORONIAL LAW - Suicide; mental health assessment; ED triage; police response

 

Inquest into the death of Kenneth MAWBY

Decision of Deputy State Coroner Dillon on the 18 December 2014

Catchwords: CORONIAL LAW - cause and manner of death, suicide of patient following Deep Brain Stimulation ("DBS") procedure for Parkinson's Disease, whether DBS was causally linked to suicide, whether patient & family informed of potential risks of procedure, whether patient appropriately followed up following procedure, whether there were systemic failures, steps taken to improve management of DBS patients, recommendations, referral of clinician to Queensland health Ombudsman

 

Inquest into the death of Massimo SUKLAN

Decision of State Coroner Barnes on 16 December 2014

Catchwords: CORONIAL LAW, drug overdose.

 

Inquest into the death of Edna Whalen

Decision of Deputy State Coroner MacMahon on the 05 December 2014

 

Inquest into the death of Frederick Alfred McGregor

Decision of Deputy State Coroner Forbes on the 09 December 2014 

Catchwords" CORONIAL LAW -death in custody- custody in court complex cells-death caused by known person

 

Inquest into the death of Norma (NB: link to findings removed to avoid the potential for prejudice in the prosecution of persons connected with this death)

Decision of State Coroner Barnes on 27 November 2014

 

​​Inquest into the death of DF

Decision of Deputy State Coroner Dillon on 27 November 2014​

Catchwords: CORONIAL LAW - death in police operations, suicide, police unable to prevent death, police action commended, police investigation commended

 

Inquest into the death of Christopher Ardill

Decision of Deputy State Coroner Freund 21 November 2014

Catchwords:CORONIAL LAW - cause and manner of death, positional asphyxia,accidental

 

Inquest into the deaths of MB and KB

Decision of Deputy State Coroner Freund 20 November 2014

Catchwords:CORONIAL LAW -cause and manner of death, Sudden Infant Death Syndrome Category II

 

Inquest into the death of Luke Wood

Decision of Deputy State Coroner Freund 19 November 2014

Catchwords:CORONIAL LAW - cause and manner of death, intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal artery, recommendation to the Director-General of the Minister of Health

 

Inquest into the death of Richard THORN

Decision of Deputy State Coroner Forbes on 11 November 2014

Catchwords: CORONIAL LAW - manner of death-decompsed-hypothermia

 

Inquest into the death of Mijin SHIN

Decision of Deputy State Coroner Freund on 5 November 2014

Catchwords: CORONIAL LAW - multiple injuries, struck by bus, recommendations to RMS

 

Inquest into the death of Amir CHOUMAN

Decision of Deputy State Coroner Forbes on 30 October 2014

Catchwords: CORONIAL LAW - death in police operation.

 

Inquest into the death of Imtissal ALAHMAD & Layal TAHAN

Decision of Deputy State Coroner Dillon on 23 October 2014

Catchwords: CORONIAL LAW - cause and manner of death, motor vehicle accident, death of passengers, cause of accident: inattention and lack of situational awareness at speed, child restraint seat not properly fitted.


 

Inquest into the death of Richard SAJKO

Decision of Deputy State Coroner Forbes on 29 September 2014

Catchwords: CORONIAL LAW - missing person, suspicious circumstances, police procedure.

 

Inquest into the death of AA

Decision of Deputy State Coroner Truscott on 26 September 2014

Catchwords: CORONIAL LAW - childhood obesity, obstructive sleep apnoea, medical neglect, care and protection.

 

Inquest into the death of Michael WILSON

Decision of Deputy State Coroner Forbes on 16 September 2014

Catchwords: CORONIAL LAW - cause and manner of death, emergency rescue, rescue co-ordination and control

 

Inquest into the death of Edward Ronald VUISSOZ

Decision of State Coroner Barnes on 12 September 2014

Catchwords: CORONIAL LAW - suspicious death

 

Inquest into the death of Stanley LORD

Decision of State Coroner Barnes on 11 September 2014

Catchwords: CORONIAL LAW - death in custody, natural causes, care and treatment.

 

Inquest into the death of GM and NJ

Decision of Deputy State Coroner Freund on 29 August 2014

Catchwords: CORONIAL LAW - manner of death, whether self-inflicted gunshot wound, firearms range, recommendations to Minister

 

Inquest into the death of Alana GOLDSMITH

Decision of Coroner Douglass on 22 August 2014

Catchwords: CORONIAL LAW - manner of death, anorexia nervosa, suicide, care and treatment, review of hospital policies and procedures,  suicide risk prevention.

 

Inquest into the death of Mark David BENNETT

Decision of Deputy State Coroner Freund on 15 August 2014

Catchwords: CORONIAL LAW - death in a police operation, police shooting, mental state of deceased, appropriateness of police action, recommendations.

 

Inquest into the death of Sean Leigh MacWilliam

Decision of Deputy State Coroner MacMahon on the 13 August 2014

 

Inquest into the death of Sarah DURAZZA

Decision of Deputy State Coroner Dillon on 8 August 2014

Catchwords: CORONIAL LAW - cause and manner of death, motor vehicle accident, single vehicle, momentary inattention or distraction of driver, probable distraction by mobile phone while driving causing loss of control of vehicle, whether safety audit of Wakehurst Parkway needed?

 

Inquest into the death of Josephine LAMBERT

Decision of Deputy State Coroner Dillon on 8 August 2014

Catchwords: CORONIAL LAW - cause and manner of death, death of psychiatric patient, whether death due to clozapine toxicity, whether treating clinicians observed protocols for administering clozapine, recommendation concerning communication between treating clinicians and forensic pathologists conducting post mortem examinations.

 

Inquest into the deaths of John GRAHAM, Ferdinand DRGANC and John DAWSON and Inquiry into the fire at 5 Alice Street, Mittagong

Decision of Deputy State Coroner Freund on 31 July 2014

Catchwords: CORONIAL LAW - cause and manner of death, residential care facility, "Sunshine Lodge and Cottages", instituting palliative care, licensing arrangements and management of facility.

 

Inquest into the death of Christopher DRAKE

Decision of Deputy State Coroner MacMahon on 22 July 2014

Catchwords: CORONIAL LAW - cause of death, response to emergency situation by public services, inherent dangers of public facilities, warnings of dangers, recommendations.

 

Inquest into the death of Scott Noel PICKFORD

Decision of Deputy State Coroner MacMahon on 21 July 2014

Catchwords: CORONIAL LAW - mandatory inquest, Death in a police operation, police pursuit, application of the NSW Police Force Safe Driving Policy.

 

Inquest into the death of Pat MORENA

Decision of Deputy State Coroner Dillon on 18 July 2014

Catchwords: CORONIAL LAW - Death in the course of police operations - Cause and manner of death - Sudden death of detained person during struggle with arresting police - Whether  due to 'excited delirium', 'positional asphyxia', or some other cause or combination of causal factors - Whether apprehension lawful - Whether excessive force used - whether method of restraint complied with standard police practice and training - Whether actions of police caused or contributed to causing death

 

Inquest into the death of Trevor John FOSTER

Decision of State Coroner Barnes on 18 July 2014

Catchwords: CORONIAL LAW - violent and unnatural death, homeless victim, mental illness.

 

Inquest into the death of Toni Ann PEADON

Decision of Deputy State Coroner Dillon on 11 July 2014

Catchwords: CORONIAL LAW - cause and manner of death, health-related procedure, extraction of cardiac device leads, surgical accident, whether procedure appropriate for this patient, whether consent procedure adequate, whether procedure performed appropriately, whether fatal injury foreseeable or preventable, whether emergency procedures appropriate, need for clarification of emergency procedure guidelines.

 

Inquest into the death of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Decision of Deputy State Coroner Forbes on 27 June 2014

Catchwords: CORONIAL LAW - cause and manner of death, drug toxicity, prescription drugs, "doctor shopping", whether doctors appropriately prescribed, Recommendations for real time prescribing

 

Inquest into the death of Mark GLEESON

Decision of Deputy State Coroner Beattie on 18 June 2014

Catchwords: CORONIAL LAW - mental health, drug and alcohol issues, respiratory distress and failure.

 

Inquest into the death of Tracylee BRANNIGAN

Decision of Deputy State Coroner MacMahon on 16 June 2014

Catchwords: CORONIAL LAW - death in custody, mandatory inquest, drug use in correctional centres

 

Inquest into the disappearance and suspected death of Jessica SMALL

Decision of Deputy State Coroner Freund on 6 June 2014

Catchwords: CORONIAL LAW - missing person, suspicious death, reward

 

Inquest into the death of Mandaswamy SHANKARANARAYANA

Decision of Deputy State Coroner Dillon on 6 June 2014

Catchwords: 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 death of Leoni Chandrika FELIX

Decision of Deputy State Coroner Dillon on 6 June 2014

Catchwords: CORONIAL LAW - cause and manner of death, homicide, domestic violence

 

Inquest into the death of Gary McKell

Decision of State Coroner Barnes on 4 June 2014

Catchwords: CORONIAL LAW - cause and manner of death, violent, unnatural death, assault, self defence

 

Inquest into the death of Beryl Joyce WATSON

Decision of State Coroner Barnes on 23 May 2014

Catchwords: CORONIAL LAW - short stay aged care residents, caring for non commutive patients in aged care facility

 

Inquest into the death of GB

Decision of Deputy State Coroner Dillon on 21 May 2014

Catchwords: 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

Decision of Deputy State Coroner Freund on 9 May 2014

Catchwords: CORONIAL LAW - Borderline personality disorder, Care and treatment, Psychiatric Care, Liverpool Hospital Mental Health Unit

 
 

Inquest into the death of Tama GALIERE

Decision of Deputy State Coroner Dillon on 9 May 2014

Catchwords: CORONIAL LAW - Cause and manner of death – Hospital death --   Whether procedure for inserting central line was appropriate given the diagnosis – Whether procedure carried out in appropriate manner – Whether line secured in appropriate fashion – How line migrated inwards causing heart damage – What has been done to mitigate chances of recurrence

 

Inquest into the death of Brendan BURNS

Decision of Deputy State Coroner Dillon on 9 May 2014

Catchwords: CORONIAL LAW – Cause and manner of death – Hospital death – Misdiagnosis of seriously-ill patient in emergency department – Failure to identify patient as critically ill – Flaws in clinical decision-making -- Systems shortcomings – Need for improved systems and training of regional surgeons

 

Inquest into the death of Hugh David LISLE

Decision of State Coroner Barnes on 8 May 2014

Catchwords: CORONIAL LAW – Mental health patients; clinical supervision; CPR in psychiatric institutions

 

Inquest into the death of Leslie ARMSTRONG

Decision of Deputy State Coroner Forbes on 2 May 2014

Catchwords: CORONIAL LAW - residential aged care facility, balcony fall due to failure of safety railing, recommendations to Minister for Planning

 

Inquest into the death of Elijah HOLCOMBE

Decision of former State Coroner Jerram on 1 May 2014

Catchwords: CORONIAL LAW - mental illness; police procedures when dealing with; shooting by police.

 

Inquest into the death of SS

Decision of State Coroner Barnes on 24 April 2014

Catchwords: CORONIAL LAW - self inflicted death, access to toxic chemicals, Poisons and Therapeutic Goods Act.

 

Inquest into the death of Jordan Leigh SARGENT

Decision of State Coroner Barnes on 7 April 2014

Catchwords: CORONIAL LAW - Death in care, supervision of a person with a disability, choking on food.

 

Inquest into the death of Hamish RAJ

Decision of Deputy State Coroner Dillon on 7 April 2014

Catchwords: CORONIAL LAW - Death in the course of a police operation, cause and manner of death, NSW police safe driving policy, Recommendations

 

Inquest into the death of Reece POTTER

Decision of Deputy State Coroner Dillon on 2 April 2014

Catchwords: CORONIAL LAW - cause and manner of death, horse racing accident, why horse fell mid-race? Whether horse struck marker post before or after falling? Whether course configuration contributed to fall? Why air retrieval helicopter not available

 

Inquest into the death of Sybil ZIMMERMAN

Decision of Deputy State Coroner Dillon on 18 March 2014

Catchwords: CORONIAL LAW, nursing home death, cause and manner of death, whether overdosed with medication, gross negligence or homicide by nursing staff, unfounded allegations: comment by Coroner.

 

Inquest into the death of Patrick HUDD

Decision of State Coroner Barnes on 17 February 2014

Catchwords: CORONIAL LAW, death in custody, natural causes, care and medical treatment of prisoners

  

Inquest into the death of Natalie WOOD

Decision of State Coroner Barnes on  5 February 2014

Catchwords: CORONIAL LAW - undiscovered human remains

 

Inquest into the death of Albert CONSTABLE

Decision of State Coroner Barnes on 31 January 2014

Catchwords: CORONIAL LAW - Heavy vehicle crash, momentary inattention, management of medical issues

 

Inquest into the death of Nicholas WATERLOW and Chloe HEUSTON - includes reasons for finding

Decision of Deputy State Coroner MacMahon on 10 January 2014

Catchwords: CORONIAL LAW - mental health, recommendations, homicide

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2013 findings and recommendations​

 

Inquest into the death of Glen PUNCH

Decision of State Coroner Jerram on 29 October 2013

Catchwords: CORONIAL LAW - Synthetic drug use, manic behaviour, illegal drugs, positional asphyxia.

 

Inquest into the disappearance and suspected death of Belinda Shirley PEISLEY

Decision of Deputy State Coroner MacMahon on 11 October 2013

Catchwords: CORONIAL LAW - missing person, unsolved homicide, recommendations to Commissioner of Police.

 

Inquest into the deaths of Eliza WANNAN and William DALTON-BROWN

Decision of Deputy State Coroner Freund on 9 October 2013

Catchwords: CORONIAL LAW - run over and crushed by motor vehicle, definition of 'road related area' in traffic legislation, proper investigation

 

Inquest into the death of Mark MASON

Decision of Deputy State Coroner Dillon on 4 October 2013

Catchwords: CORONIAL LAW - setting aside of subpoena

Inquest into the death of Kate Malonyay

Decision of Deputy State Coroner Dillon on the 29 August 2013

Catchwords: CORONERS - Cause and manner death - Homicide- domestic relationship - Identity of person killed Ms Malonyay - Whether "Known person" can be named if no longer alive at the time of the inquest Police investigation circumstantial case.

 

Inquest into the disappearance and suspected death of Rose Rain HOWELL

Decision of Deputy State Coroner MacMahon on 27 June 2013

Catchwords: CORONIAL LAW - missing person - open finding

 

Inquest into the death of Jason Lee PLUM

Decision of Deputy State Coroner Dillon on 16 May 2013

Catchwords: CORONIAL LAW - death in police custody, self-inflicted gunshot wound, police procedure, recommendations.

 

Inquest into the death of Ali Antoni EL HAFIANE

Decision of Deputy State Coroner Dillon on 29 April 2013

Catchwords: CORONIAL LAW - Death in a police operation, police procedure, armed robbery

 

Inquest into the disappearance and suspected death of Michael Kenneth CHANDLER

Decision of Deputy State Coroner MacMahon on 24 April 2013

Catchwords: CORONIAL LAW - missing person, open finding.


 

 

2012 findings and recommendations

 

Inquest into the death of Roberto Laudisio CURTO

Decision of State Coroner Jerram on 14 November 2012

Catchwords: CORONIAL LAW - death in a police operation, taser, lawfulness of arrest.

 

Inquest into the death of Michelle McILQUHAM

Decision of Deputy State Coroner Dillon in November 2012

Catchwords: CORONIAL LAW - cause and manner of death, care and treatment by hospital, undiagnosed acute streptococcus pneumonia meningitis, recommendations

 

Inquest into the death of Marcus WILSON

Decision of Deputy State Coroner Dillon on 4 October 2012

Catchwords: CORONIAL LAW - roof installation, work practices, caffeinated drinks, hyperthermia

 

Inquest into the deaths of James UNICOMB, Michael POOLE and Grace YATES

Decision of State Coroner Jerram on 27 September 2012

Catchwords: CORONIAL LAW - rapid opioid detoxification, care and treatment, drug toxicity.

 

Inquest into the death of Lynda Vanessa CLIFFORD

Decision of Deputy State Coroner Guy on 5 September 2012

Catchwords: CORONIAL LAW - mental health, drug use, communications between health professionals, Recommendations to Minister of Health

 

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR & Mohammed RAMZAN

Decision of State Coroner Jerram on 11 May 2012

Catchwords: CORONIAL LAW - 300 Hostel Marrickville, disabled & homeless facility, conditions.

 

 

 

  

Major findings pre-2012

 

Inquest into the death of Dianne BRIMBLE - findings and recommendations

Decision of Deputy State Coroner Milledge on 30 October 2010

Catchwords: CORONIAL LAW - jurisdiction of Coroner at sea, gamma hydroxybutyrate, concealment, recommendations

 

Inquest into the deaths of Alan BLINN, James ENGERT, Morgan INNES and Simone MOORE

Decision of Deputy State Coroner Dillon on 23 February 2010

Catchwords: CORONIAL LAW - ferry collision, Sydney Harbour, navigation laws and procedure, recommendations.

 

Inquest into the death of Brian Raymond PETERS (one of the "BALIBO FIVE")- Full decision and Executive Summary

Decision of Coroner Pinch on 16 November 2007

Catchwords: CORONIAL LAW - jurisdiction, background to attack on Balibo, attack, warnings and opportunities to escape, Indonesian and Australian knowledge of attach, cover-up and denial, identification and bu​rial, Journalists Code of Practice, recommendations.

  

Report of the inquest into the deaths arising from the Thredbo Landslide

Decision of State Coroner Derrick Hand on 29 June 2000

 

Newcastle Earthquake disaster 1989 - findings and recommendations

Decision of State Coroner Waller on 18 July 1990

Catchwords: CORONIAL LAW - seismology, engineering, emergency services, 13 victims, recommendations.


Inquest into the 14 deaths from the Appin Mine Disaster on the 24 July 1979

Decision of Coroner Hiatt on 19 December 1980

Catchwords: CORONIAL LAW, cause of explosion, applicable legislation, recommendations

 

Inquiry into the fire and deaths at Luna Park

Decision of Coroner Kevin Anderson on 3 September 1979

Catchwords: CORONIAL LAW - Ghost train fire, 7 deaths, possible criminal negligence, safety precautions.


 
 

 

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