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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
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
John Pace COR 2013 5350 Finding into death without inquest 29/10/2014 Coroner Phillip Byrne
Margaret Pace COR 2013 5349 Finding into death without inquest 29/10/2014 Coroner Phillip Byrne
Kyle William Vassil COR 2010 0661 Finding into death with inquest 27/10/2014 Coroner Peter White
James Robert Winchester COR 2013 2555 Finding into death with inquest 17/10/2014 Coroner Peter White
Sharga Amos Taite COR 2008 3598 Finding into death with inquest 17/10/2014 Coroner Audrey Jamieson
Zane Will McLaughlin COR 2008 1678 Finding into death with inquest 16/10/2014 State Coroner Judge Ian L Gray