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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
    Zoran Georgievski COR 2011 1267 Finding into death with inquest 10/04/2015 Coroner John Olle
    Tomislav Brekalo COR 2012 0990 Finding into death without inquest 09/04/2015 Coroner Audrey Jamieson
    Ashton Prentice Victor Meadows COR 2014 002978 Finding into death without inquest 06/04/2015 Deputy State Coroner Paresa Spanos
    Maria Teresa Nigro COR 2009 0829 Finding into death with inquest 02/04/2015 Coroner Audrey Jamieson
    Joseph Mallia COR 2013 0635 Finding into death with inquest 02/04/2015 Deputy State Coroner Paresa Spanos
    Anthony William Dunning COR 2011 2480 Finding into death with inquest 27/03/2015 State Coroner Judge Ian L Gray
    Colin David Johnson COR 2011 1758 Finding into death with inquest 27/03/2015 State Coroner Judge Ian L Gray
    Kathleen Gladwyn Downes COR 1997 3954 Finding into death with inquest 27/03/2015 State Coroner Judge Ian L Gray
    Dalvir Singh COR 2014 0867 Finding into death with inquest 26/03/2015 Coroner Jacqui Hawkins
    Brian Glenn Milnes COR 2009 5594 Finding into death without inquest 26/03/2015 Coroner Audrey Jamieson