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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
Daniel Paul Sheehy COR 2012 0934 Finding into death with inquest 19/02/2015 State Coroner Judge Ian L Gray
Margaret Teresa O'Donnell COR 2013 1327 Finding into death without inquest 17/02/2015 Coroner Rosemary Carlin
Dianne Willma MacIntyre COR 2012 1909 Finding into death without inquest 16/02/2015 Coroner John Olle
Marzieh Rahimi COR 2007 4719 Finding into death without inquest 13/02/2015 State Coroner Judge Ian L Gray
Mary Mulqueen COR 2009 3886 Finding into death with inquest 12/02/2015 Coroner John Olle
CB COR 2012 4587 Finding into death without inquest 06/02/2015 Deputy State Coroner Paresa Spanos
Muhammad Mohsin Azam COR 2012 5467 Finding into death without inquest 06/02/2015 State Coroner Judge Ian L Gray
Joan Coutts COR 2009 2381 Finding into death with inquest 04/02/2015 Deputy State Coroner Paresa Spanos
Andrew John Griffith COR 2011 2323 Finding into death without inquest 04/02/2015 Coroner John Olle
Theodore Atsaves COR 2011 4387 Finding into death without inquest 02/02/2015 Coroner Rosemary Carlin