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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
Jignesh Kumar Ghanshyamdas Sadhu COR 2008 0042 Finding into death without inquest 29/08/2014 Coroner Peter White
Noella Rae Clohesy COR 2006 4376 Finding into death with inquest 29/08/2014 State Coroner Judge Ian L Gray
Michael Atakelt COR 2011 2479 Finding into death with inquest 28/08/2014 State Coroner Judge Ian L Gray
Andrew Ngo COR 2012 3858 Finding into death without inquest 28/08/2014 Coroner Caitlin English
Michael Atakelt COR 2011 2479 Finding into death with inquest 28/08/2014 State Coroner Judge Ian L Gray
Lily Irwin COR 2012 4248 Finding into death with inquest 28/08/2014 Coroner Rosemary Carlin
Robert Vivian Hawkins COR 2010 0520 Finding into death with inquest 27/08/2014 Coroner Jacinta Heffey
Dominic Birch COR 2013 3834 Finding into death with inquest 26/08/2014 Coroner Caitlin English
Sean Brindle COR 2008 5817 Finding into death with inquest 25/08/2014 Deputy State Coroner Paresa Spanos
James Emmet Wilkinson COR 2012 0307 Finding into death without inquest 25/08/2014 Coroner Peter White