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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
    Nathan Fazal Francis COR 2007 1212 Finding into death with inquest 01/06/2012 Coroner Audrey Jamieson
    Michael John Jonson COR 2007 1339 Finding into death with inquest 27/07/2015 Coroner Audrey Jamieson
    Broughton Hall Inquest COR 2007 1371 Finding into death with inquest 25/06/2012 State Coroner Judge Ian L Gray
    Broughton Hall Inquest COR 2007 1371 Finding into death with inquest 25/06/2012 State Coroner Judge Ian L Gray
    Broughton Hall Inquest COR 2007 1371 Finding into death with inquest 25/06/2012 State Coroner Judge Ian L Gray
    Charbel Atallah COR 2007 1374 Finding into death with inquest 08/12/2016 State Coroner Judge Sara Hinchey
    Lachlan James Bingham COR 2007 1389 Finding into death with inquest 30/04/2015 Deputy State Coroner Iain West
    Adam Justin White COR 2007 1478 Finding into death with inquest 13/03/2013 Coroner Peter White
    David Ian Waghorn COR 2007 1487 Finding into death with inquest 10/06/2010 Coroner John Olle
    Joanne Elizabeth Howell COR 2007 1498 Finding into death with inquest 26/08/2011 Deputy State Coroner Paresa Spanos