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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
Claire Marguerite Martin COR 2014 3714 Finding into death without inquest 22/11/2016 Coroner Audrey Jamieson
Maria Elizabeth Valler COR 2015 2093 Finding into death without inquest 17/11/2016 Coroner Audrey Jamieson
Neil Lawrence Williamson COR 2015 1640 Finding into death with inquest 17/11/2016 Deputy State Coroner Paresa Spanos
John Raynox Jansen COR 2013 0160 Finding into death with inquest 11/11/2016 Coroner Caitlin English
Beverley Joy Leggett COR 2014 6263 Finding into death without inquest 10/11/2016 Coroner Caitlin English
Troy Daniel Saint COR 2013 0855 Finding into death without inquest 07/11/2016 Coroner Audrey Jamieson
Peter Edward Hall COR 2013 4912 Finding into death without inquest 28/10/2016 Deputy State Coroner Paresa Spanos
Zane Bradbury COR 2014 2384 Finding into death without inquest 28/10/2016 State Coroner Judge Sara Hinchey
Gladys Yvonne Melhuish COR 2015 1799 Finding into death without inquest 25/10/2016 Coroner Caitlin English
Andrew Michael ODonnell COR 2012 5516 Finding into death with inquest 25/10/2016 Coroner Audrey Jamieson