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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
    Lesley Fallon COR 2017 2590 Finding into death without inquest 08/03/2018 Coroner Peter White
    Samuel Carl Johansen COR 2012 4727 Finding into death with inquest 28/02/2018 Deputy State Coroner Paresa Spanos
    Louis Oliver Tate COR 2015 5382 Finding into death with inquest 26/02/2018 Coroner Phillip Byrne
    Kenneth James Stephens COR 2016 5017 Finding into death with inquest 23/02/2018 Coroner Peter White
    Hilda Billman COR 2017 4216 Finding into death with inquest 23/02/2018 Coroner Peter White
    Alexander Sheng Wei Li COR 2016 6011 Finding into death without inquest 23/02/2018 Deputy State Coroner Iain West
    Stanislaw Edward Czubryj COR 2017 1790 Finding into death without inquest 22/02/2018 Coroner Audrey Jamieson
    Margaret Ann Yeomans COR 2016 3703 Finding into death without inquest 19/02/2018 Coroner Audrey Jamieson
    Nicole Amanda Chatfield COR 2016 5068 Finding into death without inquest 13/02/2018 Coroner Rosemary Carlin
    Sandra Mary Carroll COR 2016 5310 Finding into death without inquest 12/02/2018 Coroner Caitlin English