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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
Jacob Austin Kermeen COR 2015 1069 Finding into death with inquest 26/09/2018 Deputy State Coroner Iain West
Gerald Vanderwerf COR 2017 5810 Finding into death with inquest 18/09/2018 Coroner Audrey Jamieson
Paquita Goldberg COR 2013 0577 Finding into death with inquest 17/09/2018 Coroner John Olle
Lynette Roberts COR 2010 4793 Finding into death with inquest 14/09/2018 Coroner Jennifer Tregent
Andrew Bond COR 2017 3245 Finding into death with inquest 13/09/2018 Coroner Michelle Hodgson
Brooke Smith COR 2017 6378 Finding into death without inquest 12/09/2018 Coroner Peter White
Robert James Wright COR 2017 3270 Finding into death without inquest 03/09/2018 Coroner Michelle Hodgson
Barry Lawrence Purtell COR 2014 3017 Finding into death with inquest 31/08/2018 Deputy State Coroner Paresa Spanos
David William Lobb COR 2014 3256 Finding into death with inquest 31/08/2018 Deputy State Coroner Paresa Spanos
Andrew John O'Dwyer COR 2015 4647 Finding into death without inquest 30/08/2018 Coroner Caitlin English