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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 Case type Date Coroner Sort descending Related orders and rulings Responses to recommendations
    Timothy Jack Wood COR 2005 2539 Finding into death with inquest 08/12/2009 Deputy State Coroner Iain West
    Susan Bourke COR 2009 4280 Finding into death with inquest 18/08/2016 Deputy State Coroner Iain West
    Sean Wayne Lee COR 2008 4470 Finding into death with inquest 17/02/2011 Deputy State Coroner Iain West
    Lynsie Maree Everett COR 2015 4707 Finding into death without inquest 18/07/2017 Deputy State Coroner Iain West
    Christopher John Stewart COR 2017 0344 Finding into death with inquest 26/03/2019 Deputy State Coroner Iain West
    Lachlan James Bingham COR 2007 1389 Finding into death with inquest 30/04/2015 Deputy State Coroner Iain West
    Mary Welsh COR 2010 2420 Finding into death with inquest 13/07/2011 Deputy State Coroner Iain West
    Kenneth John Lister COR 2012 2654 Finding into death with inquest 16/12/2013 Deputy State Coroner Iain West
    Dean Withall COR 2008 3565 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Abuk Derder Akek COR 2016 1161 Finding into death without inquest 07/11/2018 Deputy State Coroner Iain West