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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
    Stuart Beverley COR 2005 1182 Finding into death with inquest 31/01/2013 Deputy State Coroner Paresa Spanos
    Salvatore Accardo COR 2008 0913 Finding into death with inquest 31/01/2013 Deputy State Coroner Paresa Spanos
    Burnley Tunnel Deaths COR 2007 1127 Finding into death with inquest 30/01/2013 State Coroner Judge Jennifer Coate
    Abdi Hassan COR 2009 0286 Finding into death with inquest 29/01/2013 State Coroner Judge Jennifer Coate
    Daryl Wayne Nankervis COR 2010 1603 Finding into death without inquest 22/01/2013 Coroner Ann McGarvie
    Gaylee Antillia Kati COR 2004 2249 Finding into death without inquest 21/01/2013 Coroner Dr Jane Hendtlass
    Margaret Grace McCreddan COR 2011 0580 Finding into death with inquest 16/01/2013 Coroner Jonathan G Klestadt
    Neil Qualtrough COR 2010 4771 Finding into death with inquest 16/01/2013 State Coroner Judge Jennifer Coate
    Norton Beal-Guilfoyle COR 2009 0004 Finding into death with inquest 16/01/2013 Coroner Audrey Jamieson
    Steven Johnstone COR 2010 0259 Finding into death with inquest 21/12/2012 Coroner Heather Spooner