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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
    Drew William Ritchie COR 2006 0222 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    Mark Ritchie COR 2006 0223 Finding into death with inquest 18/06/2010 Deputy State Coroner Paresa Spanos
    SF COR 2006 0276 Finding into death with inquest 19/06/2014 Coroner Rosemary Carlin
    Trevor James Day COR 2006 0303 Finding into death with inquest 27/04/2010 Coroner Audrey Jamieson
    Kara Lennah Compton COR 2006 0441 Finding into death with inquest 12/11/2010 Coroner John Olle
    Mario Rocco Condello COR 2006 0505 Finding into death with inquest 08/12/2016 State Coroner Judge Sara Hinchey
    Stephen William Summers COR 2006 0650 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass
    Mr M COR 2006 0834 Finding into death without inquest 28/07/2011 State Coroner Judge Jennifer Coate
    Perera and Perera COR 2006 0873 Finding into death with inquest 03/07/2012 State Coroner Judge Jennifer Coate
    John Christopher Hender COR 2006 0950 Finding into death with inquest 05/06/2013 Coroner Dr Jane Hendtlass