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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
    Linda Parker COR 2011 4654 Finding into death without inquest 30/08/2016 State Coroner Judge Sara Hinchey
    Robert James Alexander Angus Anstice COR 2015 4768 Finding into death without inquest 23/11/2016 Coroner Audrey Jamieson
    Stephanie Jean Winberg COR 2009 4922 Finding into death without inquest 28/11/2014 State Coroner Judge Ian L Gray
    ARCHIVE Finding Hunter Joseph Stewart COR 2012 4996 Finding into death without inquest 12/02/2016 Deputy State Coroner Paresa Spanos
    Marjorie Edith St Clair COR 2013 5123 Finding into death without inquest 20/01/2015 Coroner Rosemary Carlin
    Sandra Mary Carroll COR 2016 5310 Finding into death without inquest 12/02/2018 Coroner Caitlin English
    Bryan Joseph Clothier COR 2014 5764 Finding into death without inquest 14/04/2015 Coroner Phillip Byrne
    Baby B COR 2014 4591 Finding into death without inquest 26/10/2018 Coroner Caitlin English
    Vicki Maree Hay COR 2018 4042 Finding into death without inquest 28/03/2019 Coroner Phillip Byrne
    Seker Yildiz COR 2015 2302 Finding into death without inquest 15/02/2019 Deputy State Coroner Iain West