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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
    Gurpal Sandhu COR 2007 0126 Finding into death with inquest 07/05/2013 Coroner Audrey Jamieson
    Stuart Fraser Ronaldson COR 2007 0129 Finding into death with inquest 30/04/2010 Coroner John Olle
    Jodi Joy McPaul COR 2007 0167 Finding into death with inquest 22/12/2009 Deputy State Coroner Paresa Spanos
    Mark Andrew Downie COR 2007 0197 Finding into death with inquest 25/05/2010 Coroner E. C. Batt
    Melva Jean Staff COR 2007 0234 Finding into death with inquest 28/07/2011 Coroner Kim M. W. Parkinson
    Peter Andrew Ross COR 2007 0254 Finding into death with inquest 28/10/2011 Coroner John Olle
    Lauren Katherine James COR 2007 0300 Finding into death with inquest 06/08/2010 Deputy State Coroner Paresa Spanos
    Owen Appleby COR 2007 0341 Finding into death with inquest 16/06/2011 Coroner Ronald Saines
    Bradley Keith Piper COR 2007 0350 Finding into death with inquest 02/07/2013 Coroner John Olle
    Bradley Piper COR 2007 0350 Finding into death with inquest 02/07/2013 Coroner John Olle