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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
Renee Andrea Treen COR 2010 2062 Finding into death with inquest 29/01/2014 Coroner Heather Spooner
Adam Sasha Omerovic COR 2010 1114 Finding into death with inquest 24/01/2014 Coroner Peter White
Adam Sasha Omerovic COR 2010 1114 Finding into death with inquest 24/01/2014 Coroner Peter White
Keith Flower COR 2012 0706 Finding into death without inquest 23/01/2014 Coroner John Olle
Kate Tamma Miller COR 2011 3855 Finding into death without inquest 23/01/2014 Deputy State Coroner Paresa Spanos
Dean Watt COR 2012 2512 Finding into death without inquest 22/01/2014 Coroner Rosemary Carlin
Hannah McNeil COR 2011 4307 Finding into death without inquest 22/01/2014 Deputy State Coroner Paresa Spanos
Eddie Teck Chuan Lee COR 2008 1481 Finding into death with inquest 21/01/2014 Deputy State Coroner Paresa Spanos
Jacinta OBrien COR 2012 2330 Finding into death with inquest 21/01/2014 Deputy State Coroner Iain West
Paul Jody Thornell COR 2011 4573 Finding into death with inquest 20/01/2014 State Coroner Judge Ian L Gray