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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
    Caterina Montalto COR 2011 2017 Finding into death with inquest 18/12/2013 Coroner Heather Spooner
    Mauro Corrado Amato COR 2011 1180 Finding into death without inquest 17/12/2013 Coroner Heather Spooner
    Kenneth John Lister COR 2012 2654 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Clarence Sharrock COR 2013 2489 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Luke Andrew Hyatt COR 2012 5435 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Peter Robert Williams COR 2012 1116 Finding into death without inquest 13/12/2013 State Coroner Judge Ian L Gray
    JM COR 2009 4213 Finding into death with inquest 09/12/2013 Coroner Kim M. W. Parkinson
    Merrilyn Elaine Ireland COR 2013 2355 Finding into death with inquest 06/12/2013 Coroner Phillip Byrne
    Unknown remains comprising bones COR 2012 2319 Finding into death with inquest 05/12/2013 Coroner Kim M. W. Parkinson
    AVA COR 2012 4225 Finding into death with inquest 05/12/2013 Coroner Kim M. W. Parkinson