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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
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
Jordan Marcus Farr Pang COR 2013 5898 Finding into death with inquest 17/02/2017 Coroner Audrey Jamieson
Reginald Alexander Julian Thaggard COR 2013 5897 Finding into death with inquest 17/02/2017 Coroner Audrey Jamieson
James Peter Berias COR 2014 1790 Finding into death without inquest 17/02/2017 State Coroner Judge Sara Hinchey
Savannah Price-Mihayo COR 2014 2013 Finding into death without inquest 14/02/2017 State Coroner Judge Sara Hinchey
Indianna Price-Mihayo COR 2014 2014 Finding into death without inquest 14/02/2017 State Coroner Judge Sara Hinchey
Esther Ng Kit Ching COR 2012 4823 Finding into death with inquest 07/02/2017 Coroner Peter White