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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
Margaret Elizabeth Barton COR 2015 1527 Finding into death without inquest 30/11/2017 Deputy State Coroner Iain West
Sabri Saljiu COR 2016 994 Finding into death without inquest 21/11/2017 State Coroner Judge Sara Hinchey
Judith Faye Myors COR 2016 4985 Finding into death without inquest 21/11/2017 State Coroner Judge Sara Hinchey
Graeme Harold Griffiths COR 2015 4937 Finding into death without inquest 20/11/2017 Deputy State Coroner Paresa Spanos
Alexander James McCulloch COR 2016 1020 Finding into death without inquest 17/11/2017 Coroner Peter White
Garry Serve COR 2015 5924 Finding into death without inquest 15/11/2017 Deputy State Coroner Paresa Spanos
Sandra Michelle Liddy COR 2015 6339 Finding into death with inquest 14/11/2017 Coroner Caitlin English
Baher Kondos COR 2014 3941 Finding into death without inquest 31/10/2017 Coroner Caitlin English
Henry Charles Ackerman COR 2016 5607 Finding into death without inquest 31/10/2017 Coroner Caitlin English
Andrew John Harman COR 2016 3905 Finding into death without inquest 31/10/2017 Coroner Caitlin English