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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 Sort descending Coroner Related orders and rulings Responses to recommendations
    Luke Axente Jurj COR 2007 3903 Finding into death with inquest 24/05/2010 Coroner John Olle
    Phillip William Banner COR 2009 4243 Finding into death with inquest 24/05/2010 Coroner John Olle
    Mark Andrew Downie COR 2007 0197 Finding into death with inquest 25/05/2010 Coroner E. C. Batt
    Katherine Fiona Walton COR 2007 1561 Finding into death with inquest 28/05/2010 Deputy State Coroner Paresa Spanos
    Paul Alexander Goodwin COR 2007 3976 Finding into death with inquest 31/05/2010 Coroner John Olle
    Eileen Frances Wilson COR 2009 3663 Finding into death with inquest 01/06/2010 Coroner John Olle
    Ian Richard Ford COR 2009 3897 Finding into death with inquest 07/06/2010 Coroner H C Alsop
    Mark Bailey COR 2005 1377 Finding into death with inquest 09/06/2010 Coroner Kim M. W. Parkinson
    Anthony Hogarth-Clarke COR 2005 1376 Finding into death with inquest 09/06/2010 Coroner Kim M. W. Parkinson
    Dale Graham Russ COR 2008 0142 Finding into death with inquest 10/06/2010 Deputy State Coroner Paresa Spanos