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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
Kenneth James Stephens COR 2016 5017 Finding into death with inquest 23/02/2018 Coroner Peter White
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
Kevin Simon Porker COR 2017 1567 Finding into death without inquest 06/02/2018 Deputy State Coroner Paresa Spanos
Friederike Antonia Ruhle COR 2015 3242 Finding into death without inquest 02/02/2018 Deputy State Coroner Paresa Spanos
Joy Maree Guppy COR 2015 0531 Finding into death without inquest 01/02/2018 Coroner Rosemary Carlin
GM COR 2015 6259 Finding into death without inquest 01/02/2018 Coroner John Olle
Devlin Charles Duffy COR 2016 4031 Finding into death without inquest 01/02/2018 Coroner Audrey Jamieson