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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
Connor Michael Tolson COR 2015 4765 Finding into death with inquest 29/01/2018 Coroner Audrey Jamieson
Jeffrey Coote COR 2017 1011 Finding into death without inquest 19/01/2018 Coroner Audrey Jamieson
John Gale COR 2016 3619 Finding into death without inquest 17/01/2018 Coroner Rosemary Carlin
Emma Kate McGrath COR 2017 2066 Finding into death without inquest 15/01/2018 Coroner Peter White
Karen Marie Ryan COR 2016 5084 Finding into death without inquest 12/01/2018 Coroner Rosemary Carlin
Kathryn Maree Jelbart COR 2016 6193 Finding into death without inquest 08/01/2018 Coroner John Olle
Mark Jordan-Hill COR 2016 5253 Finding into death without inquest 08/01/2018 State Coroner Judge Sara Hinchey
Sally Elizabeth Hopwood COR 2012 1193 Finding into death with inquest 21/12/2017 Coroner Peter White
James Lin COR 2016 0350 Finding into death without inquest 19/12/2017 Coroner Rosemary Carlin
Charlie Zarkadis COR 2016 5236 Finding into death without inquest 15/12/2017 Coroner Caitlin English