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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
Kevin Chuter COR 2005 1553 Finding into death without inquest 16/10/2018 Coroner Richard Pithouse
Leli Pulis COR 2016 5171 Finding into death without inquest 16/10/2018 Coroner Caitlin English
John Richard Connelly COR 2016 4766 Finding into death without inquest 11/10/2018 Coroner Audrey Jamieson
Sununtha Suttha COR 2017 0935 Finding into death without inquest 11/10/2018 Coroner Audrey Jamieson
Joseph Vitale COR 2017 4561 Finding into death with inquest 11/10/2018 Coroner Phillip Byrne
Baby W COR 2014 0201 Finding into death without inquest 05/10/2018 Coroner Caitlin English
Yvonne Rose Vizard COR 2015 4178 Finding into death with inquest 05/10/2018 Coroner Caitlin English
Mrs Z COR 2015 0048 Finding into death without inquest 05/10/2018 Coroner Caitlin English
Anthony Francis Carnevale COR 2015 6555 Finding into death with inquest 30/09/2018 Deputy State Coroner Paresa Spanos
Elizabeth Mary Gorman COR 2012 3703 Finding into death with inquest 27/09/2018 Coroner Peter White