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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Adrian Martin Young COR 2011 1575 Finding into death with inquest 23/03/2012 Coroner John Olle
    TH COR 2005 1625 Finding into death with inquest 19/08/2013 State Coroner Judge Ian L Gray
    Terence Bernard and Christine Elizabeth Hodson COR 2004 1710 Finding into death with inquest 31/07/2015 State Coroner Judge Ian L Gray
    Justin Christopher Piotrowski COR 2012 1774 Finding into death with inquest 16/07/2014 Coroner Audrey Jamieson
    Angela Murray COR 2009 1833 Finding into death with inquest 25/06/2012 Coroner Audrey Jamieson
    Lawrence George Noyes COR 2010 1890 Finding into death with inquest 27/02/2012 Coroner John Olle
    Darren Brett Kingma COR 2007 1964 Finding into death with inquest 19/03/2014 Coroner Jacqui Hawkins
    Samir Ograzden COR 2008 2028 Finding into death with inquest 04/07/2014 Coroner Audrey Jamieson
    Harold Louis COR 2009 2059 Finding into death with inquest 14/12/2012 Coroner Kim M. W. Parkinson
    Chien Diu Hoang COR 2011 2149 Finding into death with inquest 31/08/2016 State Coroner Judge Sara Hinchey