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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
    Lena Divola COR 2008 0028 Finding into death with inquest 20/05/2011 Coroner Peter White
    Alan Bishop COR 2008 4253 Finding into death without inquest 20/05/2011 Deputy State Coroner Paresa Spanos
    Garni Sulemani COR 2010 0243 Finding into death without inquest 18/05/2011 Deputy State Coroner Paresa Spanos
    Hannah Paige Pain Fowler COR 2008 2054 Finding into death with inquest 18/05/2011 Coroner Heather Spooner
    Ralph Graeme Keat COR 2010 1395 Finding into death with inquest 17/05/2011 Coroner Audrey Jamieson
    Aaron COR 2008 1430 Finding into death with inquest 16/05/2011 State Coroner Judge Jennifer Coate
    Strathewen Unknown DVI COR 2009 1442 Finding into death with inquest 13/05/2011 State Coroner Judge Jennifer Coate
    Marysville Unknown DVI COR 2009 1536 Finding into death with inquest 13/05/2011 State Coroner Judge Jennifer Coate
    Paul Kenneth Stephens COR 2008 1187 Finding into death with inquest 11/05/2011 State Coroner Judge Jennifer Coate
    Abdurahman Kuti COR 2010 4490 Finding into death without inquest 10/05/2011 Coroner H C Alsop