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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
    Angelo Raffaelle Palma COR 2015 5029 Finding into death with inquest 07/03/2017 Deputy State Coroner Paresa Spanos
    Daniel Christian McKindley COR 2016 0412 Finding into death without inquest 28/02/2017 Coroner Audrey Jamieson
    Rosario Pezzano COR 2010 1494 Finding into death with inquest 23/02/2017 State Coroner Judge Sara Hinchey
    Carey Livingstone James COR 2015 2478 Finding into death without inquest 23/02/2017 Coroner Audrey Jamieson
    Goet Wo Tjoeng COR 2015 3645 Finding into death without inquest 23/02/2017 Coroner Audrey Jamieson
    KD COR 2014 2501 Finding into death without inquest 22/02/2017 Coroner Rosemary Carlin
    Livinia Rose Kenna COR 2016 1714 Finding into death without inquest 21/02/2017 Coroner Peter White
    PAR COR 2014 4216 Finding into death without inquest 21/02/2017 Deputy State Coroner Paresa Spanos
    Ms A COR 2016 2418 Finding into death with inquest 20/02/2017 Coroner Jacqui Hawkins
    Christopher Albert Nance COR 2015 4750 Finding into death without inquest 17/02/2017 Coroner Audrey Jamieson