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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
Susan Michelle Patterson COR 2009 5286 Finding into death with inquest 18/07/2011 State Coroner Judge Jennifer Coate
Cecil John Dunne COR 2011 0060 Finding into death without inquest 17/07/2011 Coroner F Hayes
Mary Welsh COR 2010 2420 Finding into death with inquest 13/07/2011 Deputy State Coroner Iain West
Nuray Yurekturk COR 2010 4139 Finding into death with inquest 13/07/2011 Deputy State Coroner Iain West
Hugh McKay COR 2011 0452 Finding into death with inquest 12/07/2011 Coroner Ian Maxwell Von Einem
Cara Grace Zambelli COR 2006 3652 Finding into death with inquest 11/07/2011 Coroner Audrey Jamieson
Jan Szustak COR 2010 0926 Finding into death with inquest 08/07/2011 Coroner John Olle
Tzu Lin Yang COR 2010 4903 Finding into death with inquest 06/07/2011 Deputy State Coroner Iain West
Robert William Keith COR 2010 2434 Finding into death with inquest 28/06/2011 Coroner F Hayes
Faye Gwynneth Lancashire COR 2005 1138 Finding into death with inquest 23/06/2011 Coroner John Olle