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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
    Noah Zunde COR 2015 0846 Finding into death with inquest 14/06/2017 State Coroner Judge Sara Hinchey
    Kevin Suares COR 2016 2599 Finding into death without inquest 13/06/2017 Coroner Rosemary Carlin
    Dermot Michael O'Toole COR 2013 3056 Finding into death with inquest 08/06/2017 State Coroner Judge Sara Hinchey
    Geoffrey Stuart McInnes COR 2015 5123 Finding into death without inquest 07/06/2017 Coroner Rosemary Carlin
    Samer Rony Damouni COR 2015 3498 Finding into death with inquest 07/06/2017 Deputy State Coroner Iain West
    Constantinos Bekiaris COR 2016 1102 Finding into death without inquest 05/06/2017 Coroner Audrey Jamieson
    Warren Frederick Glover COR 2015 5622 Finding into death without inquest 31/05/2017 Coroner Jacqui Hawkins
    Nerilee Elizabeth Barfoot COR 2013 1568 Finding into death with inquest 31/05/2017 Deputy State Coroner Paresa Spanos
    Steele Tyson Moller COR 2017 0728 Finding into death without inquest 31/05/2017 Coroner Jacqui Hawkins
    Moira McCarthy COR 2013 1952 Finding into death without inquest 30/05/2017 Coroner Gregory McNamara