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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Khuong An Huynh COR 2009 0021 Finding into death with inquest 19/10/2012 Coroner Kim M. W. Parkinson
    Hugh Peter Bourke COR 2011 0078 Finding into death with inquest 07/09/2011 Coroner Dr Jane Hendtlass
    Stuart Fraser Ronaldson COR 2007 0129 Finding into death with inquest 30/04/2010 Coroner John Olle
    Melva Jean Staff COR 2007 0234 Finding into death with inquest 28/07/2011 Coroner Kim M. W. Parkinson
    Heather Jane Kinder COR 2011 0270 Finding into death with inquest 21/06/2013 Coroner Kim M. W. Parkinson
    Bradley Keith Piper COR 2007 0350 Finding into death with inquest 02/07/2013 Coroner John Olle
    Corey David Bray COR 2015 0455 Finding into death with inquest 27/06/2017 Coroner Peter White
    Terence Joseph Roadley COR 2014 0537 Finding into death with inquest 15/12/2014 Coroner Paresa Spanos
    Zeina Taouk COR 2014 0578 Finding into death with inquest 19/01/2015 Coroner John Olle
    Ivo John Martinov COR 2007 0612 Finding into death with inquest 21/11/2013 Coroner Dr Jane Hendtlass