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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
Peter Van Danh COR 2014 4684 Finding into death with inquest 22/03/2017 State Coroner Judge Sara Hinchey
John Twycross COR 2011 1984 Finding into death with inquest 10/03/2017 Deputy State Coroner Paresa Spanos
Matthew Williams COR 2014 6552 Finding into death with inquest 10/03/2017 Coroner Rosemary Carlin
Patricia Margaret Busby COR 2014 4052 Finding into death with inquest 09/03/2017 State Coroner Judge Sara Hinchey
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