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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. Anyone 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
    Hizir Ferman COR 2016 3497 Finding into death with inquest 05/07/2019 Coroner Rosemary Carlin
    Vincenzo Bellina COR 2016 5845 Finding into death with inquest 17/07/2019 Coroner John Olle
    Marco Angelo Virgona COR 2017 2418 Finding into death with inquest 18/09/2019 Coroner Michelle Hodgson
    Gary James Cook COR 2009 0015 Finding into death with inquest 11/10/2012 Coroner Gerard Robert Bryant
    Lorraine Therese Patrick COR 2011 0067 Finding into death with inquest 18/09/2012 Coroner Heather Spooner
    Leanne Margaret Patterson COR 2013 0122 Finding into death with inquest 16/11/2015 State Coroner Judge Ian L Gray
    Drew William Ritchie COR 2006 0222 Finding into death with inquest 18/06/2010 Coroner Paresa Spanos
    Stuart Hill COR 2008 0333 Finding into death with inquest 05/10/2011 Coroner Peter White
    Sarah Lavinia Simpson COR 2012 0400 Finding into death with inquest 11/12/2014 Coroner Jacinta Heffey
    Darcey Iris COR 2009 0447 Finding into death with inquest 30/10/2015 State Coroner Judge Ian L Gray