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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
    William John Colhoun COR 2008 5618 Finding into death with inquest 15/08/2013 Deputy State Coroner Iain West
    Robert Theodore Stewart COR 2013 5853 Finding into death with inquest 21/03/2014 Coroner Phillip Byrne
    Dean Alan Carlson Laycock COR 2009 5950 Finding into death with inquest 30/04/2015 Coroner Jennifer Tregent
    Wieslaw Albin Bernacki COR 2009 6039 Finding into death with inquest 05/12/2014 Deputy State Coroner Paresa Spanos
    Marc Phillip Vella COR 2014 6358 Finding into death with inquest 14/10/2015 Coroner Jacqui Hawkins
    Priyantha Nirmale Ranjith Peiris COR 2016 5671 Finding into death with inquest 09/11/2018 Deputy State Coroner Paresa Spanos
    Barry Lawrence Purtell COR 2014 3017 Finding into death with inquest 31/08/2018 Deputy State Coroner Paresa Spanos
    Pauline Mary Riordan COR 2013 5924 Finding into death with inquest 31/01/2019 Deputy State Coroner Paresa Spanos
    Ercil Jean Webb COR 2007 2133 Finding into death with inquest 21/10/2013 Coroner Dr Jane Hendtlass
    Ernest Hyde COR 2018 4519 Finding into death with inquest 11/06/2019 Coroner Rosemary Carlin