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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
    Bruce John Camp COR 2019 1610 Finding into death without inquest 04/02/2020 Coroner John Olle
    Francis John Stewart COR 2018 3515 Finding into death without inquest 31/01/2020 Coroner Jacqui Hawkins
    Damon Brenden Amiet COR 2013 1584 Finding into death with inquest 31/01/2020 Deputy State Coroner Paresa Spanos
    X Y COR 2016 6058 Finding into death without inquest 31/01/2020 Coroner Darren Bracken
    Ward Harker COR 2015 6083 Finding into death with inquest 31/01/2020 Coroner Darren Bracken

    Alfred Health was required to respond by 12 May 2020. The effects of COVID-19 have caused a delay, however a response is expected after August 2020.

    Brett Maybus COR 2017 4320 Finding into death with inquest 31/01/2020 Coroner Phillip Byrne
    Adele Di Quinzio COR 2016 4948 Finding into death without inquest 30/01/2020 Coroner Jacqui Hawkins
    Prisoner A COR 2018 4087 Finding into death without inquest 29/01/2020 Coroner John Olle
    Caitlin-Lei Alaya COR 2018 5553 Finding into death without inquest 29/01/2020 Coroner Simon McGregor
    Prisoner A COR 2018 4087 Finding into death without inquest 29/01/2020 Coroner John Olle