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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 Sort ascending Coroner Related orders and rulings Responses to recommendations
    Graham Hill COR 2018 0285 Finding into death without inquest 04/12/2018 Coroner Michelle Hodgson
    Anna Agnieszka Bowditch COR 2014 4262 Finding into death with inquest 03/12/2018 Coroner Audrey Jamieson

    Royal Australasian College of Surgeons were required to respond by 5 March 2019. No response has been received to date.

    Albert Dean May COR 2015 4237 Finding into death without inquest 29/11/2018 Coroner Audrey Jamieson
    Nikolaos Margelis COR 2014 5980 Finding into death with inquest 29/11/2018 Coroner Simon McGregor
    Douglas John Angus COR 2017 6386 Finding into death without inquest 28/11/2018 Coroner Simon McGregor
    Jason William Causon COR 2018 2769 Finding into death without inquest 28/11/2018 Coroner Phillip Byrne
    Amber-Rose Beard COR 2015 5078 Finding into death without inquest 28/11/2018 Coroner Caitlin English
    Sarah Hammoud COR 2016 1306 Finding into death with inquest 26/11/2018 Coroner Jacqui Hawkins
    Emma Ashlee Dutton COR 2013 5916 Finding into death with inquest 26/11/2018 Deputy State Coroner Paresa Spanos
    Michael Phu Tran COR 2017 5048 Finding into death without inquest 23/11/2018 Coroner Michelle Hodgson