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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
    Garry Montgomery Theobold COR 2014 0888 Finding into death with inquest 11/07/2017 Deputy State Coroner Paresa Spanos
    Chloe Breanna Blackney COR 2014 0887 Finding into death with inquest 11/07/2017 Deputy State Coroner Paresa Spanos
    Khodayar Amini COR 2015 5275 Finding into death without inquest 10/07/2017 Deputy State Coroner Iain West
    SO COR 2016 3735 Finding into death without inquest 07/07/2017 Coroner Gregory McNamara
    Ronald Edgar Kolody COR 2015 5121 Finding into death without inquest 07/07/2017 Coroner Rosemary Carlin
    Ze Cheng (Tony) Guan COR 2014 3658 Finding into death with inquest 07/07/2017 Coroner Gregory McNamara
    NJ COR 2015 2127 Finding into death without inquest 04/07/2017 Coroner Rosemary Carlin
    Margaret Penny and Claire Acocks COR 1991 1444 Finding into death with inquest 30/06/2017 Coroner Jacqui Hawkins
    Peter James Nolan COR 2013 4262 Finding into death with inquest 29/06/2017 Coroner Peter White
    Polina Portnyagina COR 2015 4604 Finding into death without inquest 29/06/2017 Coroner Audrey Jamieson