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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
    Nicholas James Coulson COR 2013 0820 Finding into death with inquest 19/06/2015 Deputy State Coroner Paresa Spanos
    Baby Chloe Lee Kellett COR 2009 2102 Finding into death with inquest 12/06/2015 Deputy State Coroner Paresa Spanos
    Neil Alfred Middling COR 2014 3854 Finding into death without inquest 04/06/2015 Coroner Rosemary Carlin
    Suzanne Berg COR 2013 2276 Finding into death without inquest 31/05/2015 Deputy State Coroner Paresa Spanos
    Ignac Lecek COR 2007 3964 Finding into death with inquest 29/05/2015 Coroner Audrey Jamieson
    Craig Doherty COR 2013 0217 Finding into death without inquest 29/05/2015 Coroner Peter White
    Majang Ngor COR 2013 2761 Finding into death with inquest 29/05/2015 Coroner Peter White
    Jack Irving COR 2014 2990 Finding into death without inquest 29/05/2015 Coroner John Olle
    Naomi Charmaine Mahon COR 2011 1282 Finding into death with inquest 28/05/2015 Deputy State Coroner Paresa Spanos
    Waldemar Ariel Ogon COR 2011 2235 Finding into death with inquest 27/05/2015 Coroner Audrey Jamieson