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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
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
Chang Ying Xu COR 2010 4578 Finding into death with inquest 26/03/2015 Deputy State Coroner Paresa Spanos
Brian Glenn Milnes COR 2009 5594 Finding into death without inquest 26/03/2015 Coroner Audrey Jamieson
Dalvir Singh COR 2014 0867 Finding into death with inquest 26/03/2015 Coroner Jacqui Hawkins
Rodney Soffer COR 2013 4506 Finding into death without inquest 25/03/2015 Coroner John Olle
Glenn Richard Altmann COR 2014 1806 Finding into death without inquest 18/03/2015 Coroner John Olle
Katrina Ruth Baron COR 2014 0431 Finding into death without inquest 18/03/2015 Coroner Phillip Byrne
Christopher John Dokos COR 2014 0430 Finding into death without inquest 18/03/2015 Coroner Phillip Byrne
John Richard Jones COR 2006 1546 Finding into death with inquest 13/03/2015 Coroner Audrey Jamieson