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 Sort descending | Date | Coroner | Related orders and rulings | Responses to recommendations |
---|---|---|---|---|---|---|
Cara Grace Zambelli | COR 2006 3652 | Finding into death with inquest | 11/07/2011 | Coroner Audrey Jamieson | ||
Roberto Di Bartolo | COR 2013 3749 | Finding into death with inquest | 08/07/2015 | Deputy State Coroner Paresa Spanos | ||
Manabu Kondo | COR 2006 3810 | Finding into death with inquest | 15/02/2012 | Coroner Peter White | ||
Raymond John O_Brien | COR 2013 3874 | Finding into death with inquest | 01/10/2014 | Coroner Jacqui Hawkins | ||
Donna Maree Gusman | COR 2015 3932 | Finding into death with inquest | 10/07/2018 | State Coroner Judge Sara Hinchey | ||
Leigh Glenn Travaglia | COR 2009 3998 | Finding into death with inquest | 14/02/2012 | Deputy State Coroner Iain West | ||
Patricia Margaret Busby | COR 2014 4052 | Finding into death with inquest | 09/03/2017 | State Coroner Judge Sara Hinchey | ||
Avjit Singh | COR 2012 4188 | Finding into death with inquest | 30/10/2015 | State Coroner Judge Ian L Gray | ||
AVA | COR 2012 4225 | Finding into death with inquest | 05/12/2013 | Coroner Kim M. W. Parkinson | ||
Maria Liordos | COR 2013 4288 | Finding into death with inquest | 01/08/2017 | Coroner Audrey Jamieson | |