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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
    Paul Bermingham COR 2013 5778 Finding into death with inquest 18/12/2015 Coroner Audrey Jamieson
    Katie Isabelle Peters COR 2013 0649 Finding into death with inquest 17/12/2015 Coroner John Olle
    Steven Kadar COR 2013 0648 Finding into death with inquest 17/12/2015 Coroner John Olle
    Andrew Stanyer COR 2014 5831 Finding into death with inquest 16/12/2015 Coroner Jacqui Hawkins
    Fay Dawn Rogers COR 2014 6309 Finding into death without inquest 15/12/2015 Coroner Rosemary Carlin
    Kathleen Raven COR 2012 0324 Finding into death without inquest 10/12/2015 Coroner Michelle Hodgson
    Dane Alexander Hortle COR 2012 0380 Finding into death without inquest 10/12/2015 Deputy State Coroner Iain West
    Benjamin David Johnston COR 2015 1002 Finding into death without inquest 09/12/2015 Coroner Jacqui Hawkins
    Jeffrey John Hartwig COR 2009 5822 Finding into death with inquest 07/12/2015 Coroner John Olle
    Baby Kylie Hamilton COR 2009 3481 Finding into death with inquest 04/12/2015 Deputy State Coroner Paresa Spanos