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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
Nidhi Parashar COR 2012 2201 Finding into death with inquest 30/11/2015 State Coroner Judge Ian L Gray
Maria Dolores Coliero COR 2011 3564 Finding into death with inquest 30/11/2015 Deputy State Coroner Paresa Spanos
Murrindindi Fire COR 2009 1498 Finding into fire without inquest 27/11/2015 State Coroner Judge Ian L Gray
Eoin Stephen Murray COR 2013 4033 Finding into death with inquest 27/11/2015 State Coroner Judge Ian L Gray
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
IL Gambero Restaurant Fire COR 2009 4103 Finding into fire with inquest 23/11/2015 Coroner Audrey Jamieson
Timothy Joseph De Voigt COR 2009 5966 Finding into death 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