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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. Anyone 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
    Yik Sua Hong COR 2017 5638 Finding into death without inquest 20/01/2020 Coroner Caitlin English
    Travis Lee Fernandez COR 2014 5936 Finding into death with inquest 14/01/2020 Coroner Paresa Spanos
    A S COR 2017 2215 Finding into death without inquest 14/01/2020 Coroner Simon McGregor
    Annie Chettle COR 2019 0586 Finding into death without inquest 13/01/2020 Coroner Simon McGregor
    H B COR 2013 3373 Finding into death with inquest 13/01/2020 Coroner Sarah Gebert
    Caitlin-Lei Alaya COR 2018 5553 Finding into death without inquest 13/01/2020 Coroner Simon McGregor
    Patricia Faye Stone COR 2018 0896 Finding into death without inquest 06/01/2020 Coroner Audrey Jamieson
    Samuel Alexander Chilton COR 2019 0849 Finding into death without inquest 06/01/2020 Coroner Michelle Hodgson
    Thien Cong Pham COR 2012 5518 Finding into death with inquest 17/12/2019 Coroner Paresa Spanos
    Kyle Horne COR 2018 1218 Finding into death without inquest 13/12/2019 Coroner Caitlin English