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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
    James Thomas Smith COR 2008 0359 Finding into death with inquest 02/11/2011 State Coroner Judge Jennifer Coate
    Rory COR 2005 2510 Finding into death with inquest 31/10/2011 Coroner Jennifer Tregent
    Karenne King COR 2011 0568 Finding into death with inquest 28/10/2011 Coroner John Olle
    Peter Andrew Ross COR 2007 0254 Finding into death with inquest 28/10/2011 Coroner John Olle
    Terri Elizabeth Musgrave COR 2010 3687 Finding into death with inquest 28/10/2011 Coroner John Olle
    John Threadgold COR 2011 1079 Finding into death with inquest 26/10/2011 Coroner Kim M. W. Parkinson
    Redae Berhane COR 2011 1258 Finding into death with inquest 26/10/2011 State Coroner Judge Jennifer Coate
    Dale Graeme Cook COR 2011 2720 Finding into death with inquest 24/10/2011 Coroner Kim M. W. Parkinson
    Claus J Neff COR 2008 2719 Finding into death with inquest 21/10/2011 Coroner Peter White
    Jeremy Edward Chandler COR 2009 1449 Finding into death with inquest 20/10/2011 Coroner Heather Spooner