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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
Kathleen Raven COR 2012 0324 Finding into death without inquest 10/12/2015 Coroner Michelle Hodgson
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
Khodr El Mustapha COR 2013 4295 Finding into death without inquest 02/12/2015 Coroner Audrey Jamieson
Justin Damien Connell COR 2013 0653 Finding into death without inquest 02/12/2015 Deputy State Coroner Paresa Spanos
James Willian Steele COR 2013 1711 Finding into death with inquest 01/12/2015 Coroner Jacqui Hawkins
Anitha Mathew, Philip , Mathew George COR 2012 2038 Finding into death with inquest 30/11/2015 State Coroner Judge Ian L Gray
Asim Kumar COR 2012 2202 Finding into death with inquest 30/11/2015 State Coroner Judge Ian L Gray
Yasmina Micheline Acar COR 2010 4416 Finding into death with inquest 30/11/2015 State Coroner Judge Ian L Gray