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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
    David Ian Waghorn COR 2007 1487 Finding into death with inquest 10/06/2010 Coroner John Olle
    Kelvin Lea Swab COR 2008 4630 Finding into death with inquest 11/06/2010 Coroner Audrey Jamieson
    Mark Ritchie COR 2006 0223 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    George Panayiotis COR 2006 0221 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    Warwick Lorne Greville COR 2006 0220 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    Drew William Ritchie COR 2006 0222 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    Michael Alexander La Franchi COR 2009 3545 Finding into death with inquest 21/06/2010 Coroner Dr Jane Hendtlass
    Ashley William Seedsman COR 2009 3685 Finding into death with inquest 21/06/2010 Coroner Dr Jane Hendtlass
    Leonie Bedggood COR 2008 5666 Finding into death without inquest 22/06/2010 Coroner Tim McDonald
    Daryl Rolton COR 2009 1473 Finding into death without inquest 25/06/2010 Coroner Kim M. W. Parkinson