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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
    Zahra Rahimzadegan COR 2012 0131 Finding into death without inquest 27/11/2015 State Coroner Judge Ian L Gray
    Kerran Lyn Hills COR 2015 2435 Finding into death without inquest 25/11/2015 Coroner Peter White
    Timothy Joseph De Voigt COR 2009 5966 Finding into death with inquest 23/11/2015 Coroner Audrey Jamieson
    IL Gambero Restaurant Fire COR 2009 4103 Finding into fire with inquest 23/11/2015 Coroner Audrey Jamieson
    Sherry Ann Robinson COR 2010 2023 Finding into death without inquest 19/11/2015 State Coroner Judge Ian L Gray
    Leanne Margaret Patterson COR 2013 0122 Finding into death with inquest 16/11/2015 State Coroner Judge Ian L Gray
    James John Russouw COR 2008 0984 Finding into death with inquest 09/11/2015 Coroner Audrey Jamieson
    Saber Zakaria Sulieman COR 2014 2875 Finding into death without inquest 08/11/2015 Coroner Rosemary Carlin
    Katie Louise Broadbent COR 2014 0551 Finding into death without inquest 06/11/2015 State Coroner Judge Ian L Gray
    Kasim Colic COR 2015 0567 Finding into death with inquest 05/11/2015 State Coroner Judge Ian L Gray