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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
    Dianne Chi COR 2015 0999 Finding into death with inquest 01/04/2016 State Coroner Judge Sara Hinchey
    Andrew Simon Beare COR 2015 2032 Finding into death without inquest 04/03/2016 State Coroner Judge Sara Hinchey
    Julie Ann Garciacelay COR 2001 2158 Finding into death with inquest 11/04/2018 State Coroner Judge Sara Hinchey
    Anne Whitelegg COR 2014 4862 Finding into death without inquest 11/04/2018 State Coroner Judge Sara Hinchey
    Sabri Saljiu COR 2016 994 Finding into death without inquest 21/11/2017 State Coroner Judge Sara Hinchey
    Deepshikha Godara COR 2014 6332 Finding into death with inquest 08/08/2016 State Coroner Judge Sara Hinchey
    Les Samba COR 2011 0762 Finding into death with inquest 31/08/2017 State Coroner Judge Sara Hinchey
    Carmelo Gusman COR 2015 3931 Finding into death without inquest 10/07/2018 State Coroner Judge Sara Hinchey
    Child W COR 2011 4815 Finding into death without inquest 06/04/2017 State Coroner Judge Sara Hinchey
    COR 2012 4919 Finding into death without inquest 14/03/2018 State Coroner Judge Sara Hinchey