Inquest into the death of BQ

Case Number: 2021/00205817

Date of Findings: 29 September 2025

Magistrate: Deputy State Coroner, Magistrate David O'Neil

CORONIAL LAW – young Indigenous woman, mental health, involuntary detention, public guardian, observations in mental health ward, access to scarf used as a ligature, Aboriginal Liaison Officers in Western Sydney Local Health District, Covid-19 times, cultural training within the Public Guardian

Responses

Recommendations

To the Chief Executive Officer of the NSW Trustee and Guardian

1. That the Chief Executive Officer of the NSW Trustee and Guardian make arrangements to provide First Nation’s cultural competency training to all NSW Trustee and Guardian staff with a priority to those working with Aboriginal and Torres Strait Islander clients (and with consideration to periodically repeating such training).

1. A copy of the Court's findings into the inquest into the death of BQ be referred to the New South Wales Attorney General.