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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
    Manabu Kondo COR 2006 3810 Finding into death with inquest 15/02/2012 Coroner Peter White
    Rosamaria Lauria COR 2006 3826 Finding into death with inquest 20/07/2011 State Coroner Judge Jennifer Coate
    Bayden Roy Smith COR 2006 3973 Finding into death with inquest 03/03/2010 State Coroner Judge Jennifer Coate
    Matthew Jack Whyte COR 2006 4010 Finding into death with inquest 03/03/2015 Coroner Peter White
    Gail Fergusson COR 2006 4171 Finding into death with inquest 17/04/2014 Coroner Jacqui Hawkins
    Elizabeth Maryanne Holley COR 2006 4197 Finding into death with inquest 23/01/2012 Deputy State Coroner Iain West
    Lionel Raymond Perry COR 2006 4204 Finding into death with inquest 22/07/2011 Coroner Audrey Jamieson
    Marcus Michael Christopher Charles COR 2006 4223 Finding into death with inquest 17/03/2014 Coroner Peter White
    Russell John Robert McLarty COR 2006 4248 Finding into death with inquest 26/06/2013 Coroner Dr Jane Hendtlass
    Russell John Robert McLarty COR 2006 4248 Finding into death with inquest 26/06/2013 Coroner Dr Jane Hendtlass