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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 descending Coroner Related orders and rulings Responses to recommendations
    Bonnie Elizabeth Tyler COR 2009 5977 Finding into death with inquest 17/01/2011 Coroner John Olle
    Carolyn Veronica Dean COR 2010 1895 Finding into death with inquest 24/01/2011 Coroner Jonathan G Klestadt
    Chas Birch COR 2008 2276 Finding into death with inquest 28/01/2011 Deputy State Coroner Paresa Spanos
    Chas Birch COR 2008 2276 Finding into death with inquest 28/01/2011 Deputy State Coroner Paresa Spanos
    Frederick Goggin COR 1996 3530 Finding into death with inquest 01/02/2011 Coroner Kim M. W. Parkinson
    Lindsay Dickson COR 2009 2351 Finding into death without inquest 03/02/2011 Coroner Heather Spooner
    Wei Han Chang COR 2009 4826 Finding into death with inquest 08/02/2011 Coroner Kim M. W. Parkinson
    Christine Mary Humphrey COR 2009 4827 Finding into death with inquest 08/02/2011 Coroner Kim M. W. Parkinson
    John William Brown COR 2009 1913 Finding into death with inquest 17/02/2011 Coroner John Olle
    Michael William Gledhill COR 2008 5241 Finding into death with inquest 17/02/2011 Coroner Kim M. W. Parkinson