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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
    Anthony Hogarth-Clarke COR 2005 1376 Finding into death with inquest 09/06/2010 Coroner Kim M. W. Parkinson
    Mark Bailey COR 2005 1377 Finding into death with inquest 09/06/2010 Coroner Kim M. W. Parkinson
    Linda Jane Stilwell COR 2005 1489 Finding into death with inquest 30/10/2014 Deputy State Coroner Iain West
    Kevin Chuter COR 2005 1553 Finding into death without inquest 16/10/2018 Coroner Richard Pithouse
    TH COR 2005 1625 Finding into death with inquest 19/08/2013 State Coroner Judge Ian L Gray
    Sebastian Hewitt COR 2005 1927 Finding into death with inquest 06/08/2012 Deputy State Coroner Paresa Spanos
    Kathryn Margaret Ray COR 2005 2434 Finding into death with inquest 26/06/2014 Coroner Audrey Jamieson
    Russell James Arthur Lee COR 2005 2435 Finding into death with inquest 26/06/2014 Coroner Audrey Jamieson
    Brian Ray COR 2005 2436 Finding into death with inquest 26/06/2014 Coroner Audrey Jamieson
    Rory COR 2005 2510 Finding into death with inquest 31/10/2011 Coroner Jennifer Tregent