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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
    Warren Guneratne COR 2008 0418 Finding into death with inquest 07/10/2014 Coroner Audrey Jamieson
    Grazia Giosserano COR 2008 0483 Finding into death with inquest 17/04/2014 Coroner Paresa Spanos
    Pelelini Sooula COR 2017 0548 Finding into death with inquest 10/07/2018 State Coroner Judge Sara Hinchey
    Robert Dunlop COR 2011 0581 Finding into death with inquest 04/06/2012 Coroner Kim M. W. Parkinson
    Carmelina Rachela Sirianni COR 2007 0671 Finding into death with inquest 07/05/2013 Coroner Audrey Jamieson
    John Kabiru Ndirangu COR 2009 0715 Finding into death with inquest 03/03/2015 Coroner Peter White
    Margaret Lurline Martyr-Paterson COR 2010 0814 Finding into death with inquest 31/03/2014 Coroner Audrey Jamieson
    Unknown Bones COR 2009 0924 Finding into death with inquest 30/08/2010 Deputy State Coroner Iain West
    Robert Richard Hoff COR 2011 0980 Finding into death with inquest 29/06/2017 State Coroner Judge Sara Hinchey
    Vishna Mary Damke COR 2013 1080 Finding into death with inquest 14/07/2014 Coroner Rosemary Carlin