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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
    Simon Peter Gardner COR 2009 3877 Finding into death with inquest 15/03/2011 Coroner John Olle
    David Travaglia COR 2009 3999 Finding into death with inquest 14/02/2012 Deputy State Coroner Iain West
    John Mackenzie COR 2012 4145 Finding into death with inquest 08/08/2013 Coroner Kim M. W. Parkinson
    Werner Viertmann COR 2012 4191 Finding into death with inquest 04/04/2016 Deputy State Coroner Paresa Spanos
    Peter James Nolan COR 2013 4262 Finding into death with inquest 29/06/2017 Coroner Peter White
    Justin John Fraser COR 2007 4293 Finding into death with inquest 13/03/2013 Coroner Peter White
    Donna Maria Mousely COR 2010 4352 Finding into death with inquest 08/06/2012 Deputy State Coroner Iain West
    Dwayne Robertson COR 2010 4401 Finding into death with inquest 06/12/2012 Coroner Peter White
    Findings Adang Akot COR 2012 4496 Finding into death with inquest 12/06/2013 Coroner John Olle
    Snezana Stojanovska COR 2010 4552 Finding into death with inquest 30/07/2018 State Coroner Judge Sara Hinchey