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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Patrica June Andrew COR 2010 4317 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Joanne Feeney COR 2010 4374 Finding into death with inquest 29/02/2012 Deputy State Coroner Paresa Spanos
    Rhys Andrew Rodger COR 2010 4518 Finding into death with inquest 04/07/2013 Coroner William P. Gibb
    Baby Mabel Windmill COR 2012 4563 Finding into death with inquest 15/07/2015 Coroner Jacqui Hawkins
    Angelo Lombardo COR 2005 4746 Finding into death with inquest 07/06/2011 Coroner Audrey Jamieson
    Margaret Elizabeth Anne Jones COR 2008 4805 Finding into death with inquest 17/06/2011 Deputy State Coroner Paresa Spanos
    Luiza Eftimova COR 2008 5023 Finding into death with inquest 23/03/2012 Coroner John Olle
    Nancy May Budge COR 2016 5227 Finding into death with inquest 11/09/2017 State Coroner Judge Sara Hinchey
    Nikos Vourdoulidis COR 2008 5266 Finding into death with inquest 27/05/2013 Coroner Kim M. W. Parkinson
    Joanne Margaret Burgess COR 2012 5377 Finding into death with inquest 18/02/2014 Coroner Peter White