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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
    David Robert Judge McVea COR 2007 0708 Finding into death with inquest 02/10/2014 Coroner Peter White
    Anthony John Roach COR 2007 0739 Finding into death with inquest 26/06/2013 Coroner Dr Jane Hendtlass
    Peter Robin Tully COR 2007 0791 Finding into death with inquest 17/05/2012 Coroner Dr Jane Hendtlass
    Lynette May Phillips COR 2007 0860 Finding into death with inquest 10/12/2012 State Coroner Judge Jennifer Coate
    HiepThi Nguyen COR 2007 0865 Finding into death with inquest 20/12/2013 Coroner John Olle
    Benjamin Jason Pappas COR 2007 0957 Finding into death with inquest 12/10/2012 State Coroner Judge Jennifer Coate
    Marlene Kenny COR 2007 1090 Finding into death without inquest 29/07/2011 Deputy State Coroner Iain West
    Kath Bergamin COR 2007 1111 Finding into death with inquest 04/06/2008 Coroner Peter White
    Burnley Tunnel Deaths COR 2007 1127 Finding into death with inquest 30/01/2013 State Coroner Judge Jennifer Coate
    Lee Patrica Collings COR 2007 1142 Finding into death with inquest 31/01/2012 Coroner Dr Jane Hendtlass