Skip to main content Skip to home page

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
    Unknown Remains COR 2010 2001 Finding into death with inquest 30/08/2010 Deputy State Coroner Iain West
    Kelly Maree Richards COR 2011 2565 Finding into death with inquest 14/04/2016 Deputy State Coroner Iain West
    Vontharasmey Ban COR 2009 3951 Finding into death with inquest 10/10/2013 Deputy State Coroner Iain West
    Elizabeth Maryanne Holley COR 2006 4197 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Vincent Anthony Bonanno COR 2011 0859 Finding into death without inquest 27/02/2013 Deputy State Coroner Iain West
    Anthony Mandel COR 2007 1877 Finding into death with inquest 21/07/2011 Deputy State Coroner Iain West
    Francis John Willcox COR 2008 2696 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Magdalena Schauer COR 2007 4443 Finding into death with inquest 22/03/2010 Deputy State Coroner Iain West
    Kam Wah Koh COR 2010 4963 Finding into death without inquest 17/11/2014 Deputy State Coroner Iain West
    George Iles COR 2009 5007 Finding into death with inquest 14/02/2012 Deputy State Coroner Iain West