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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
Lloyd Douglas Hill COR 2015 4278 Finding into death without inquest 12/09/2016 Coroner Audrey Jamieson
Suzil Oghia COR 2013 5025 Finding into death without inquest 08/09/2016 State Coroner Judge Sara Hinchey
Cathy Mary McPhee COR 2013 0054 Finding into death without inquest 05/09/2016 Coroner Audrey Jamieson
Jarrod Joseph Debono COR 2015 4662 Finding into death without inquest 01/09/2016 Coroner Audrey Jamieson
Chien Diu Hoang COR 2011 2149 Finding into death with inquest 31/08/2016 State Coroner Judge Sara Hinchey
Nathan Dimech COR 2013 4969 Finding into death without inquest 31/08/2016 Coroner Caitlin English
Leigh Joseph Riley COR 2015 2490 Finding into death with inquest 31/08/2016 State Coroner Judge Sara Hinchey
COR 2016 0708 Finding into death without inquest 30/08/2016 Coroner Jacqui Hawkins
Linda Parker COR 2011 4654 Finding into death without inquest 30/08/2016 State Coroner Judge Sara Hinchey
Melissa Jane May COR 2013 5788 Finding into death without inquest 26/08/2016 Coroner Rosemary Carlin