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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
    Carmelo Gusman COR 2015 3931 Finding into death without inquest 10/07/2018 State Coroner Judge Sara Hinchey
    Pelelini Sooula COR 2017 0548 Finding into death with inquest 10/07/2018 State Coroner Judge Sara Hinchey
    Eugene William Twining COR 2016 3244 Finding into death without inquest 28/06/2018 Coroner Audrey Jamieson
    Raymond John Cox COR 2014 2220 Finding into death without inquest 28/06/2018 Deputy State Coroner Paresa Spanos
    Gultekin Yuksel COR 2018 0196 Finding into death without inquest 27/06/2018 Coroner Peter White
    Luke John De Piazza COR 2017 1099 Finding into death with inquest 26/06/2018 Coroner Phillip Byrne
    Liaqat Ali Hamid Kayani COR 2014 3425 Finding into death with inquest 22/06/2018 Deputy State Coroner Paresa Spanos
    Amanda Dawson COR 2016 4867 Finding into death without inquest 20/06/2018 State Coroner Judge Sara Hinchey
    Giuseppe Costa COR 2016 4782 Finding into death without inquest 18/06/2018 Coroner Audrey Jamieson

    Western Health (Not Received)

    Ian John Gilbert COR 2015 0742 Finding into death with inquest 14/06/2018 Coroner Rosemary Carlin