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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
Pedro Arcos-Vazquez COR 2010 4337 Finding into death with inquest 12/09/2014 State Coroner Judge Ian L Gray
Daniel Raymond Cowan COR 2012 4283 Finding into death with inquest 11/09/2014 Coroner John Olle
Llona Elizabeth Doolan COR 2012 0220 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
John William Macfie COR 2014 1261 Finding into death with inquest 10/09/2014 Coroner John Olle
Glenni Goodwin Ker COR 2006 1100 Finding into death with inquest 09/09/2014 Coroner Audrey Jamieson
Nathan Andrew Roberts-Nunan COR 2009 0732 Finding into death without inquest 08/09/2014 Coroner John Olle
Kirstan McRae-Jansen COR 2012 0070 Finding into death with inquest 01/09/2014 Coroner Peter White
Sunil Ramanlal Patel COR 2008 0041 Finding into death without inquest 29/08/2014 Coroner Peter White
Deepak Kumar Prajapati COR 2008 0043 Finding into death without inquest 29/08/2014 Coroner Peter White