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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
Norton Beal-Guilfoyle COR 2009 0004 Finding into death with inquest 16/01/2013 Coroner Audrey Jamieson
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
Steven Johnstone COR 2010 0259 Finding into death with inquest 21/12/2012 Coroner Heather Spooner
Mathew Lister COR 2010 0258 Finding into death with inquest 21/12/2012 Coroner Heather Spooner
William Te-Whare COR 2010 0257 Finding into death with inquest 21/12/2012 Coroner Heather Spooner
Benjamin Hall COR 2010 0256 Finding into death with inquest 21/12/2012 Coroner Heather Spooner
Jeanette Brown COR 2008 5233 Finding into death with inquest 14/12/2012 Coroner Kim M. W. Parkinson
Harold Louis COR 2009 2059 Finding into death with inquest 14/12/2012 Coroner Kim M. W. Parkinson
David William Macumber COR 2010 2668 Finding into death without inquest 13/12/2012 Coroner Michelle Hodgson