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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
Robert Peter Ferrier COR 2013 0654 Finding into death with inquest 01/07/2015 Deputy State Coroner Paresa Spanos
John Wilfred Knight COR 2014 2123 Finding into death with inquest 30/06/2015 Coroner Phillip Byrne
Terri Anne Woolley-Peresso COR 2012 4193 Finding into death without inquest 23/06/2015 Coroner Rosemary Carlin
Stephen Robert Blom COR 2014 2638 Finding into death without inquest 22/06/2015 Coroner Caitlin English
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
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