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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
    Iman Kassis COR 2008 4559 Finding into death with inquest 30/09/2014 Deputy State Coroner Paresa Spanos
    Jeremy Bradley Edwards COR 2012 1868 Finding into death without inquest 30/09/2014 Coroner Caitlin English
    Neil Phillip Hay COR 2013 5470 Finding into death without inquest 29/09/2014 Deputy State Coroner Iain West
    Kelvin Robert Davidson COR 2007 3955 Finding into death with inquest 29/09/2014 Coroner Peter White
    Lucia Amenta COR 2009 5098 Finding into death with inquest 18/09/2014 State Coroner Judge Ian L Gray
    Pedro Arcos-Vazquez COR 2010 4337 Finding into death with inquest 12/09/2014 State Coroner Judge Ian L Gray
    Nola Margaret Moxon COR 2009 0577 Finding into death with inquest 12/09/2014 Coroner Peter White
    Llona Elizabeth Doolan COR 2012 0220 Finding into death with inquest 11/09/2014 Coroner John Olle
    Daniel Raymond Cowan COR 2012 4283 Finding into death with inquest 11/09/2014 Coroner John Olle
    Lloyd Felman COR 2008 2867 Finding into death with inquest 11/09/2014 Coroner Jacqui Hawkins