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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 ascending Date Coroner Related orders and rulings Responses to recommendations
    Japanese Screens and Interiors Fire COR 2007 4864 Finding into fire with inquest 23/08/2010 Coroner Heather Spooner
    Noah Philip James Sheekey COR 2009 0169 Finding into death without inquest 19/11/2014 Coroner Jacinta Heffey
    Caroline Emily Lovell COR 2012 0293 Finding into death without inquest 24/03/2016 Coroner Peter White
    Peter James COR 2011 0442 Finding into death without inquest 25/08/2011 Coroner Paul Anthony Smith
    Eli Ian Marnock COR 2015 1006 Finding into death without inquest 14/07/2017 Coroner Peter White
    Bridget Louise Jones COR 2013 1368 Finding into death without inquest 04/06/2018 State Coroner Judge Sara Hinchey
    Daryl Wayne Nankervis COR 2010 1603 Finding into death without inquest 22/01/2013 Coroner Ann McGarvie
    James Peter Berias COR 2014 1790 Finding into death without inquest 17/02/2017 State Coroner Judge Sara Hinchey
    Richard Hilton COR 2011 1852 Finding into death without inquest 17/09/2013 Deputy State Coroner Paresa Spanos
    Sharmaine Vera Blyth COR 2015 1897 Finding into death without inquest 07/09/2015 Coroner Phillip Byrne