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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Norton Beal-Guilfoyle COR 2009 0004 Finding into death with inquest 16/01/2013 Coroner Audrey Jamieson
    Lena Divola COR 2008 0028 Finding into death with inquest 20/05/2011 Coroner Peter White
    Justin Peter Foster COR 2012 0021 Finding into death with inquest 17/11/2014 Coroner Caitlin English
    David Andrew Sidebottom COR 2011 0021 Finding into death with inquest 18/10/2013 Coroner Ronald Saines
    Khuong An Huynh COR 2009 0021 Finding into death with inquest 19/10/2012 Coroner Kim M. W. Parkinson
    Miles David Colman COR 2011 0018 Finding into death with inquest 03/04/2012 Deputy State Coroner Iain West
    Gary James Cook COR 2009 0015 Finding into death with inquest 11/10/2012 Coroner Gerard Robert Bryant
    Gary James Cook COR 2009 0015 Finding into death with inquest 11/10/2012 Coroner Gerard Robert Bryant
    Carl Ranthe COR 2009 0013 Finding into death with inquest 28/02/2011 Coroner John Olle
    Claire Kathleen Fogarty COR 2011 0004 Finding into death with inquest 25/01/2012 Deputy State Coroner Iain West