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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
Stephen James Peace COR 2006 1590 Finding into death with inquest 29/04/2015 Coroner Audrey Jamieson
John Manias COR 2008 1041 Finding into death with inquest 29/04/2015 Coroner Peter White
Van Thanh Thi Do COR 2013 3177 Finding into death without inquest 28/04/2015 Coroner Caitlin English
Ian Kenneth Pye COR 2013 1501 Finding into death with inquest 23/04/2015 Deputy State Coroner Iain West
Craig Ronald McMillan COR 2013 1891 Finding into death with inquest 23/04/2015 Coroner Phillip Byrne
Grant Phillip Scheibner COR 2014 4805 Finding into death with inquest 23/04/2015 Deputy State Coroner Iain West
Mark Brian Wilson COR 2013 2058 Finding into death without inquest 22/04/2015 Coroner Audrey Jamieson
James Colin Tomlinson COR 2011 2865 Finding into death without inquest 20/04/2015 Coroner Caitlin English
Nicholas William Moorby COR 2013 1550 Finding into death with inquest 16/04/2015 Coroner Caitlin English
Bryan Joseph Clothier COR 2014 5764 Finding into death without inquest 14/04/2015 Coroner Phillip Byrne