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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 Sort descending Case type Date Coroner Related orders and rulings Responses to recommendations
    Steve Gulyas COR 2003 3526 Finding into death with inquest 11/04/2011 State Coroner Judge Jennifer Coate
    William Grant Keays COR 2003 3683 Finding into death with inquest 15/08/2008 Coroner Audrey Jamieson
    Terrence John Cottier COR 2004 0846 Finding into death with inquest 30/03/2011 Coroner H C Alsop
    Nicole Maree Knox-Smith COR 2004 1311 Finding into death with inquest 21/07/2006 State Coroner Graeme Johnstone
    Gethin Roberts COR 2004 1420 Finding into death with inquest 06/05/2005 Coroner Phillip Byrne
    Wesley Robert Jennings COR 2004 1575 Finding into death with inquest 12/02/2010 Deputy State Coroner Paresa Spanos
    Terence Bernard and Christine Elizabeth Hodson COR 2004 1710 Finding into death with inquest 31/07/2015 State Coroner Judge Ian L Gray
    Gregory Ram Biggs COR 2004 1798 Finding into death with inquest 23/10/2009 Coroner Audrey Jamieson
    Gaylee Antillia Kati COR 2004 2249 Finding into death without inquest 21/01/2013 Coroner Dr Jane Hendtlass
    Thomas James Brigham COR 2004 2347 Finding into death with inquest 20/06/2013 Deputy State Coroner Iain West