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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
    NCS COR 2012 2188 Finding into death without inquest 04/06/2013 Coroner Michelle Hodgson
    Aaron Oakley COR 2012 1854 Finding into death with inquest 04/06/2013 Coroner Kim M. W. Parkinson
    Nikos Vourdoulidis COR 2008 5266 Finding into death with inquest 27/05/2013 Coroner Kim M. W. Parkinson
    Takashi Le Minh COR 2011 2328 Finding into death with inquest 21/05/2013 Coroner Dr Jane Hendtlass
    John Crivera COR 2006 4595 Finding into death with inquest 21/05/2013 Coroner Dr Jane Hendtlass
    Francesco Vicendese COR 2010 1656 Finding into death with inquest 17/05/2013 Deputy State Coroner Paresa Spanos
    William Malcolm Warner COR 2011 1413 Finding into death without inquest 15/05/2013 Coroner Jack Vandersteen
    Luke Matthew Thomson COR 2011 2174 Finding into death with inquest 15/05/2013 Coroner Heather Spooner
    Joseph Thurgood Gates COR 2010 4851 Finding into death with inquest 10/05/2013 Coroner Kim M. W. Parkinson
    Tyler Reading-Adams COR 2007 4502 Finding into death without inquest 09/05/2013 Coroner Dr Jane Hendtlass