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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
    Barabara Lubik COR 2009 0394 Finding into death without inquest 27/11/2013 State Coroner Judge Ian L Gray
    Andrew Gilmore COR 2009 2564 Finding into death with inquest 27/11/2013 Coroner Kim M. W. Parkinson
    Kaye D Ward COR 2012 5005 Finding into death without inquest 21/11/2013 Coroner Jonathan G Klestadt
    Ivo John Martinov COR 2007 0612 Finding into death with inquest 21/11/2013 Coroner Dr Jane Hendtlass
    Robert J Ward COR 2012 5004 Finding into death without inquest 21/11/2013 Coroner Jonathan G Klestadt
    Sean Raymond Adams COR 2012 1042 Finding into death without inquest 18/11/2013 Deputy State Coroner Paresa Spanos
    Melissa Ann Ryan COR 2011 0418 Finding into death with inquest 15/11/2013 Coroner Heather Spooner
    Adrian James Keatley COR 2013 0578 Finding into death with inquest 15/11/2013 Coroner John Olle
    Jill Fielding COR 2007 2186 Finding into death without inquest 14/11/2013 Coroner Dr Jane Hendtlass
    Jill Fielding COR218607 Finding into death without inquest 14/11/2013 Coroner Dr Jane Hendtlass