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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
    Teresa Mancuso COR 2013 3101 Finding into death without inquest 10/03/2021 Deputy State Coroner Caitlin English
    Jack David watson COR 2016 3591 Finding into death without inquest 10/03/2021 Coroner Darren Bracken
    Michael Brian Sanders COR 2018 4194 Finding into death with inquest 03/03/2021 Coroner Audrey Jamieson
    Gary Hietanen COR 2017 3888 Finding into death with inquest 02/03/2021 Coroner Darren Bracken
    Scott James Adams COR 2019 1005 Finding into death without inquest 01/03/2021 Coroner Darren Bracken

    Bicycle Industries Australia was required to provide a response by 3 June 2021. No response has been received to date.

    MrJ COR 2016 5648 Finding into death without inquest 26/02/2021 Coroner Sarah Gebert
    Ian Fraser COR 2019 6921 Finding into death without inquest 26/02/2021 Deputy State Coroner Caitlin English
    Laurence Joseph Kermond COR 2019 4133 Finding into death without inquest 25/02/2021 Coroner Sarah Gebert
    Rosemary Gibson COR 2016 1676 Finding into death without inquest 25/02/2021 State Coroner Judge John Cain
    MrP COR 2017 3180 Finding into death without inquest 25/02/2021 Coroner Sarah Gebert