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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
    Grant Elliot Phillips COR 2007 1735 Finding into death with inquest 12/10/2012 Coroner Audrey Jamieson
    Mavroidis Karpetis COR 2008 5782 Finding into death with inquest 12/10/2012 State Coroner Judge Jennifer Coate
    Gary James Cook COR 2009 0015 Finding into death with inquest 11/10/2012 Coroner Gerard Robert Bryant
    Gary James Cook COR 2009 0015 Finding into death with inquest 11/10/2012 Coroner Gerard Robert Bryant
    Donald Edward Paterson COR 2011 2623 Finding into death with inquest 10/10/2012 Coroner Audrey Jamieson
    Rodney David Keegan COR 2011 2543 Finding into death with inquest 10/10/2012 Coroner Audrey Jamieson
    Christopher Barca COR 2011 1844 Finding into death with inquest 10/10/2012 Coroner Heather Spooner
    Li Zhen Gao COR 2010 3649 Finding into death with inquest 09/10/2012 Coroner Heather Spooner
    Sue Hui Wang COR 2010 3650 Finding into death with inquest 09/10/2012 Coroner Heather Spooner
    SG COR 2012 0047 Finding into death without inquest 09/10/2012 Coroner David Bruce Sidney Cottrill