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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
    Noel Robert Rogerson COR 2009 1758 Finding into death with inquest 17/08/2011 Coroner Heather Spooner
    Luciano T COR 2007 1893 Finding into death with inquest 16/08/2011 State Coroner Judge Jennifer Coate
    Lisa Irene Sharp COR 2007 5119 Finding into death with inquest 16/08/2011 Coroner Heather Spooner
    James Martin Todd COR 2009 2727 Finding into death with inquest 15/08/2011 Coroner Heather Spooner
    B COR 2009 3651 Finding into death without inquest 10/08/2011 Deputy State Coroner Paresa Spanos
    Patricia Webster COR 2009 5367 Finding into death without inquest 09/08/2011 Coroner Audrey Jamieson
    Paul Ernest Young COR 2011 0143 Finding into death with inquest 08/08/2011 Coroner John Olle
    Marlene Kenny COR 2007 1090 Finding into death without inquest 29/07/2011 Deputy State Coroner Iain West
    Unknown Human Skull and Long Bone Fragments COR 2011 1086 Finding into death with inquest 28/07/2011 Coroner Kim M. W. Parkinson
    Roy Cecil McLennan COR 2011 0698 Finding into death with inquest 28/07/2011 Coroner Kim M. W. Parkinson