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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
Margaret Helen McCall COR 2012 4064 Finding into death without inquest 15/07/2015 Coroner Audrey Jamieson
Baby Mabel Windmill COR 2012 4563 Finding into death with inquest 15/07/2015 Coroner Jacqui Hawkins
David Allan Ronald Sinclair COR 2012 2049 Finding into death with inquest 14/07/2015 State Coroner Judge Ian L Gray
Dawn Ruby Edward COR 2012 2282 Finding into death without inquest 13/07/2015 Coroner Audrey Jamieson
David Allan D'Angelo COR 2010 1306 Finding into death with inquest 08/07/2015 Deputy State Coroner Paresa Spanos
Roberto Di Bartolo COR 2013 3749 Finding into death with inquest 08/07/2015 Deputy State Coroner Paresa Spanos
Male D COR 2009 0605 Finding into death with inquest 06/07/2015 Coroner John Olle
Anthony Travaglini COR 2008 4028 Finding into death with inquest 03/07/2015 Coroner Peter White
Britt Kathryn-May Lapthorne COR 2008 4635 Finding into death with inquest 01/07/2015 State Coroner Judge Ian L Gray
Robert Charles Avery COR 2010 4389 Finding into death with inquest 01/07/2015 Deputy State Coroner Iain West