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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
    John Bernard Tuffy COR 2008 2287 Finding into death with inquest 31/01/2012 Coroner Dr Jane Hendtlass
    John Bernard Tuffy COR 2008 2287 Finding into death with inquest 31/01/2012 Coroner Dr Jane Hendtlass
    Yan Zhu Lin COR 2009 6026 Finding into death without inquest 27/01/2012 Deputy State Coroner Paresa Spanos
    Claire Kathleen Fogarty COR 2011 0004 Finding into death with inquest 25/01/2012 Deputy State Coroner Iain West
    Rosemary Jane Berg COR 2010 4363 Finding into death with inquest 25/01/2012 Deputy State Coroner Iain West
    Bradlee John Maher COR 2010 4893 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Patrica June Andrew COR 2010 4317 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Elizabeth Maryanne Holley COR 2006 4197 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Jimmy Nguyen COR 2009 6016 Finding into death without inquest 19/01/2012 Coroner Heather Spooner
    Jimmy Nguyen COR 2009 6016 Finding into death without inquest 19/01/2012 Coroner Heather Spooner