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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
    Noah Philip James Sheekey COR 2009 0169 Finding into death without inquest 19/11/2014 Coroner Jacinta Heffey
    Justin Peter Foster COR 2012 0021 Finding into death with inquest 17/11/2014 Coroner Caitlin English
    Kam Wah Koh COR 2010 4963 Finding into death without inquest 17/11/2014 Deputy State Coroner Iain West
    Allan Phipps COR 2012 4494 Finding into death with inquest 17/11/2014 Coroner Caitlin English
    Michael Patrick Ormsby COR 2010 1742 Finding into death with inquest 12/11/2014 Coroner David Bruce Sidney Cottrill
    Tamara Ann Burt COR 2011 0877 Finding into death with inquest 11/11/2014 Coroner Jacqui Hawkins
    Peter Andrew McNay COR 2012 2550 Finding into death with inquest 10/11/2014 Coroner John Olle
    David John Scott COR 2013 5908 Finding into death with inquest 07/11/2014 Coroner Audrey Jamieson
    Linda Jane Stilwell COR 2005 1489 Finding into death with inquest 30/10/2014 Deputy State Coroner Iain West
    Anne Christine Brain COR 2011 4797 Finding into death with inquest 30/10/2014 State Coroner Judge Ian L Gray