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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
Baby Isabella Rose COR 2013 3731 Finding into death with inquest 13/04/2017 Deputy State Coroner Paresa Spanos
Michael John Darmody COR 2014 2445 Finding into death with inquest 10/04/2017 Coroner John Olle
Natasha Calleja COR 2015 4329 Finding into death with inquest 07/04/2017 Coroner Rosemary Carlin
Child W COR 2011 4815 Finding into death without inquest 06/04/2017 State Coroner Judge Sara Hinchey
KP COR 2014 2874 Finding into death without inquest 05/04/2017 Coroner Rosemary Carlin
HJE COR 2014 0882 Finding into death without inquest 30/03/2017 Deputy State Coroner Paresa Spanos
Antonio Loguancio COR 2013 0934 Finding into death with inquest 30/03/2017 Coroner Audrey Jamieson
Peter Heng Dowe Chiam COR 2015 4959 Finding into death without inquest 27/03/2017 Coroner John Olle
David John Maynard COR 2016 4806 Finding into death without inquest 27/03/2017 Coroner Jacqui Hawkins
Stacey Louise Yean COR 2016 0093 Finding into death with inquest 23/03/2017 Coroner Phillip Byrne