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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
Avjit Singh COR 2012 4188 Finding into death with inquest 30/10/2015 State Coroner Judge Ian L Gray
Sargun Ragi COR 2012 4184 Finding into death with inquest 30/10/2015 State Coroner Judge Ian L Gray
Noel Imbrogno COR 2013 2868 Finding into death without inquest 30/10/2015 Coroner John Lesser
Darcey Iris COR 2009 0447 Finding into death with inquest 30/10/2015 State Coroner Judge Ian L Gray
Emilie Suzanne Le Coz COR 2010 1611 Finding into death with inquest 22/10/2015 Coroner Peter White
Denis Adrian Fitzgerald COR 2014 1886 Finding into death without inquest 22/10/2015 Deputy State Coroner Paresa Spanos
James Terrance Sullivan COR 2012 0298 Finding into death without inquest 19/10/2015 Coroner Peter White
Daniella Francesca Sessarego COR 2014 4163 Finding into death without inquest 19/10/2015 Deputy State Coroner Paresa Spanos
Flora June Rasmussen COR 2015 2397 Finding into death without inquest 16/10/2015 Coroner Peter White
Marc Phillip Vella COR 2014 6358 Finding into death with inquest 14/10/2015 Coroner Jacqui Hawkins