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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
COR 2012 0400 Finding into death with inquest 11/12/2014 Coroner Jacinta Heffey
Phoebe Handsjuk COR 2010 4605 Finding into death with inquest 10/12/2014 Coroner Peter White
Sydney Hugh Kennedy COR 2013 2766 Finding into death without inquest 10/12/2014 Coroner Michelle Hodgson
Ling Gong Tang COR 2010 1790 Finding into death with inquest 09/12/2014 Deputy State Coroner Iain West
Craig Douglas COR 2011 1554 Finding into death with inquest 08/12/2014 Coroner Phillip Byrne
Gerard Alexander Tibballs COR 2010 2404 Finding into death with inquest 08/12/2014 Coroner Audrey Jamieson
Wieslaw Albin Bernacki COR 2009 6039 Finding into death with inquest 05/12/2014 Deputy State Coroner Paresa Spanos
Anastasios Kosmas COR 2013 2202 Finding into death with inquest 04/12/2014 Coroner Phillip Byrne
Leroy William Scott COR 2011 1475 Finding into death with inquest 04/12/2014 Coroner Jacinta Heffey
Colin John Rafferty COR 2013 5494 Finding into death with inquest 01/12/2014 Coroner Phillip Byrne