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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
    Savannah Price-Mihayo COR 2014 2013 Finding into death without inquest 14/02/2017 State Coroner Judge Sara Hinchey
    Peter Van Danh COR 2014 4684 Finding into death with inquest 22/03/2017 State Coroner Judge Sara Hinchey
    Noel Faure COR 2016 6218 Finding into death without inquest 23/06/2017 State Coroner Judge Sara Hinchey
    Jacinta OBrien COR 2012 2330 Finding into death with inquest 21/01/2014 Deputy State Coroner Iain West
    Junichi Yoshimura COR 2017 4024 Finding into death without inquest 05/04/2018 Deputy State Coroner Iain West
    Nicholas Raymond Lobo COR 2008 4896 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Beatrix Dammers COR 2007 2281 Finding into death with inquest 29/07/2015 Deputy State Coroner Iain West
    Patrica June Andrew COR 2010 4317 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Wayne Brown COR 2016 2614 Finding into death without inquest 07/12/2018 Deputy State Coroner Iain West
    Gordon Harvey COR 2016 0279 Finding into death without inquest 13/02/2019 Deputy State Coroner Iain West