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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
    Cara Grace Zambelli COR 2006 3652 Finding into death with inquest 11/07/2011 Coroner Audrey Jamieson
    Roberto Di Bartolo COR 2013 3749 Finding into death with inquest 08/07/2015 Deputy State Coroner Paresa Spanos
    Manabu Kondo COR 2006 3810 Finding into death with inquest 15/02/2012 Coroner Peter White
    Raymond John O_Brien COR 2013 3874 Finding into death with inquest 01/10/2014 Coroner Jacqui Hawkins
    Donna Maree Gusman COR 2015 3932 Finding into death with inquest 10/07/2018 State Coroner Judge Sara Hinchey
    Leigh Glenn Travaglia COR 2009 3998 Finding into death with inquest 14/02/2012 Deputy State Coroner Iain West
    Patricia Margaret Busby COR 2014 4052 Finding into death with inquest 09/03/2017 State Coroner Judge Sara Hinchey
    Avjit Singh COR 2012 4188 Finding into death with inquest 30/10/2015 State Coroner Judge Ian L Gray
    AVA COR 2012 4225 Finding into death with inquest 05/12/2013 Coroner Kim M. W. Parkinson
    Maria Liordos COR 2013 4288 Finding into death with inquest 01/08/2017 Coroner Audrey Jamieson