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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
    Arthur Moumas COR 2009 3698 Finding into death with inquest 11/10/2010 State Coroner Judge Jennifer Coate
    Baby Isabella Rose COR 2013 3731 Finding into death with inquest 13/04/2017 Deputy State Coroner Paresa Spanos
    Kirat Singh COR 2013 3852 Finding into death with inquest 30/09/2015 Deputy State Coroner Paresa Spanos
    Graeme Andrew Dunn COR 2007 3914 Finding into death with inquest 13/08/2013 Coroner Dr Jane Hendtlass
    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
    Lily Irwin COR 2012 4248 Finding into death with inquest 28/08/2014 Coroner Rosemary Carlin
    Gregory John Caulfield COR 2011 4328 Finding into death with inquest 08/05/2014 Deputy State Coroner Iain West
    David Liam Goold COR 2013 4376 Finding into death with inquest 24/11/2014 Deputy State Coroner Iain West