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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
    Nathan Troy Chalkley COR 2007 0363 Finding into death with inquest 30/04/2014 Coroner Phillip Byrne
    Marie Goder COR 2011 0144 Finding into death without inquest 29/04/2014 Deputy State Coroner Iain West
    Stacey Jade Smith COR 2007 2518 Finding into death with inquest 24/04/2014 Coroner Peter White
    Mark Bethell COR 2008 1217 Finding into death with inquest 24/04/2014 Coroner Peter White
    Gail Fergusson COR 2006 4171 Finding into death with inquest 17/04/2014 Coroner Jacqui Hawkins
    Rodney Mark Moore COR 2008 0477 Finding into death with inquest 17/04/2014 State Coroner Judge Ian L Gray
    Grazia Giosserano COR 2008 0483 Finding into death with inquest 17/04/2014 Deputy State Coroner Paresa Spanos
    Darren John Parkes COR 2006 1090 Finding into death with inquest 17/04/2014 State Coroner Judge Ian L Gray
    Thomas Freemantle COR 2010 4201 Finding into death with inquest 08/04/2014 Coroner John Olle
    Kirk Ardern COR 2012 2254 Finding into death without inquest 07/04/2014 Coroner Audrey Jamieson