Inquest into the death of MQ

Case Number: 2023/00074236

Date of Findings: 17 December 2025

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – time of death, cause and manner of death, clinical progression of pneumonia, concern for welfare, New South Wales Police Force Computer Aided Dispatch system, capacity and timeframe for response at St George Police Area Command

Responses

Recommendations

To the NSW Commissioner of Police:

1. I recommend to the Commissioner of the New South Wales Police Force that consideration be given to having the St George Police Area Command review its practices, procedures and training regarding the taking of phone calls of matters which require a job to be created on the Computerised Aided Dispatch (CAD) system. This review should ensure that such processes are sufficiently robust and reliable, and that the New South Wales Police Force may respond appropriately to such jobs in accordance with its polices and standard operating procedures.