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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 Coroner Sort descending Related orders and rulings Responses to recommendations
Sharnee Ngatai COR 2014 0172 Finding into death without inquest 08/08/2018 State Coroner Judge Sara Hinchey
Carmelo Gusman COR 2015 3931 Finding into death without inquest 10/07/2018 State Coroner Judge Sara Hinchey
Child W COR 2011 4815 Finding into death without inquest 06/04/2017 State Coroner Judge Sara Hinchey
Helen Curtis COR 2012 4919 Finding into death without inquest 14/03/2018 State Coroner Judge Sara Hinchey
Wilhelm Paul Koeppen COR 2013 5308 Finding into death with inquest 11/07/2018 State Coroner Judge Sara Hinchey
Catherine Elizabeth Browning COR 2013 5843 Finding into death without inquest 09/12/2016 State Coroner Judge Sara Hinchey
Dermot Michael O'Toole COR 2013 3056 Finding into death with inquest 08/06/2017 State Coroner Judge Sara Hinchey
James Peter Berias COR 2014 1790 Finding into death without inquest 17/02/2017 State Coroner Judge Sara Hinchey
David Lay COR 2001 2245 Finding into death with inquest 08/12/2016 State Coroner Judge Sara Hinchey
Donna Maree Gusman COR 2015 3932 Finding into death with inquest 10/07/2018 State Coroner Judge Sara Hinchey