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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
    John Crivera COR 2006 4595 Finding into death with inquest 21/05/2013 Coroner Dr Jane Hendtlass
    Jonathan Paul Tozer COR 2011 4727 Finding into death with inquest 12/03/2013 Coroner Audrey Jamieson
    Michael William Gledhill COR 2008 5241 Finding into death with inquest 17/02/2011 Coroner Kim M. W. Parkinson
    Shane Gregory Hunt COR 2008 5319 Finding into death with inquest 06/03/2014 State Coroner Judge Ian L Gray
    Jarrod Wade Christie COR 2012 5456 Finding into death with inquest 30/10/2015 Coroner Caitlin English
    Tyler Cassidy COR 2008 5542 Finding into death with inquest 23/11/2011 State Coroner Judge Jennifer Coate
    Jason Shaun Kumar COR 2009 5767 Finding into death with inquest 14/07/2014 Coroner John Olle
    Mettaloka Malinda Halwala COR 2015 5857 Finding into death with inquest 10/05/2018 Coroner Rosemary Carlin
    Shida Li COR 2009 5959 Finding into death with inquest 20/04/2011 Coroner Heather Spooner
    Clarence Tuivaiese Nicholas Leo COR 2016 5542 Finding into death with inquest 09/11/2018 Deputy State Coroner Paresa Spanos