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Findings

A written finding is a formal document handed down by a coroner following an investigation into a death or fire and is generally the final step in the coronial investigation process. A written finding is made regardless of whether an inquest is held or not.

A written finding following an investigation into a death will usually, if possible, include:

  • the identity of the person who died
  • the time, date, and location where the death occurred
  • a summary of the evidence relating to the circumstances of the death, in some cases
  • comments or recommendations made by the coroner aimed at preventing similar deaths, in some cases.

Findings are published when:

  • an inquest was held
  • recommendations have been made
  • a coroner otherwise orders they be published.

Findings handed down and published are available below.

Search older findings on the Australasian Legal Information Institute database (AustLII).

Please consider that it may be upsetting to read details about a death or fire in an inquest finding. Some information may be graphic or distressing.

Use the search field above to locate a finding. You can search for a name, a case number, type of death or location of death.

Any person may apply for some or all of a finding to be reviewed and/or appealed.

    Recommendations

    The Coroners Act 2008 allows a coroner to make recommendations as part of their finding following an investigation into a death or fire.

    Recommendations can be made to any Minister, public statutory authority or entity that may help prevent similar deaths. A public statutory authority or entity who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken.

    The Court will publish inquest findings with recommendations and the subsequent responses below.

    Findings list

    Name Case ID Case type Date Coroner Sort descending Related orders and rulings Responses to recommendations
    Anne Whitelegg COR 2014 4862 Finding into death without inquest 11/04/2018 State Coroner Judge Sara Hinchey
    Sabri Saljiu COR 2016 994 Finding into death without inquest 21/11/2017 State Coroner Judge Sara Hinchey
    Deepshikha Godara COR 2014 6332 Finding into death with inquest 08/08/2016 State Coroner Judge Sara Hinchey
    Alexander Ignatius Cody COR 2010 1287 Finding into death with inquest 21/02/2013 Deputy State Coroner Iain West
    Luke Grosvero COR 2012 1551 Finding into death with inquest 07/11/2013 Deputy State Coroner Iain West
    Ling Gong Tang COR 2010 1790 Finding into death with inquest 09/12/2014 Deputy State Coroner Iain West
    Clarence Sharrock COR 2013 2489 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Edo Travaglia COR 2009 3997 Finding into death with inquest 14/02/2012 Deputy State Coroner Iain West
    Paul Francis O'Donnell COR 2016 2762 Finding into death without inquest 07/11/2018 Deputy State Coroner Iain West
    Claire Kathleen Fogarty COR 2011 0004 Finding into death with inquest 25/01/2012 Deputy State Coroner Iain West