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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
Bernadette Angelina Rogers COR 2012 5075 Finding into death with inquest 30/01/2014 Coroner Heather Spooner
BD COR 2017 5180 Finding into death with inquest 27/04/2018 Coroner Rosemary Carlin
Mavroidis Karpetis COR 2008 5782 Finding into death with inquest 12/10/2012 State Coroner Judge Jennifer Coate
Bonnie Elizabeth Tyler COR 2009 5977 Finding into death with inquest 17/01/2011 Coroner John Olle
Jake James-Kotsanas COR 2014 6196 Finding into death with inquest 14/12/2016 Coroner John Olle
Andrew Bond COR 2017 3245 Finding into death with inquest 13/09/2018 Coroner Michelle Hodgson
Baby J COR 2018 2773 Finding into death with inquest 16/07/2019 Coroner Phillip Byrne
Grant White COR 2017 4581 Finding into death with inquest 14/10/2019 Coroner Audrey Jamieson
Liaqat Ali Hamid Kayani COR 2014 3425 Finding into death with inquest 22/06/2018 Coroner Paresa Spanos
Dianne Bradley COR 2016 0418 Finding into death with inquest 11/02/2020 Coroner Audrey Jamieson