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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. Anyone 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
    Kenneth John Lister COR 2012 2654 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Sameh Matar COR 2010 2855 Finding into death with inquest 29/06/2017 State Coroner Judge Sara Hinchey
    David John McLeod COR 2012 3502 Finding into death with inquest 23/12/2014 Coroner Paresa Spanos
    Dean Withall COR 2008 3565 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Li Zhen Gao COR 2010 3649 Finding into death with inquest 09/10/2012 Coroner Heather Spooner
    Phillip George Black COR 2010 3699 Finding into death with inquest 20/02/2015 Coroner Paresa Spanos
    Anthony Ian Gaylard COR 2012 3970 Finding into death with inquest 23/09/2013 Coroner John Olle
    Eoin Stephen Murray COR 2013 4033 Finding into death with inquest 27/11/2015 State Coroner Judge Ian L Gray
    Dean Scott Westbrook COR 2005 4176 Finding into death with inquest 25/02/2010 State Coroner Judge Jennifer Coate
    JM COR 2009 4213 Finding into death with inquest 09/12/2013 Coroner Kim M. W. Parkinson