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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
Benjamin Elijah Mills COR 2013 0593 Finding into death with inquest 15/10/2014 State Coroner Judge Ian L Gray
William Morrison Nunan COR 2014 2221 Finding into death with inquest 14/10/2014 Deputy State Coroner Paresa Spanos
Lauren Kayley Harris COR 2008 4363 Finding into death with inquest 14/10/2014 Deputy State Coroner Iain West
Carl Anthony Williams COR 2010 1468 Finding into death without inquest 13/10/2014 State Coroner Judge Ian L Gray
Warren Guneratne COR 2008 0418 Finding into death with inquest 07/10/2014 Coroner Audrey Jamieson
Darren Carr Hannah COR 2012 3727 Finding into death with inquest 07/10/2014 Coroner Caitlin English
Adrian Peter Carlin COR 2013 0663 Finding into death with inquest 07/10/2014 Coroner Caitlin English
Anthony Guerra COR 2011 2219 Finding into death with inquest 06/10/2014 Coroner John Olle
Britney Jade Guerra COR 2011 2218 Finding into death with inquest 06/10/2014 Coroner John Olle
Penrin John Maxworth Halliday COR 2009 0575 Finding into death with inquest 02/10/2014 Coroner Peter White