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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
    Abuk Derder Akek COR 2016 1161 Finding into death without inquest 07/11/2018 Deputy State Coroner Iain West
    Pearl Recht COR 2011 3161 Finding into death with inquest 06/12/2012 Deputy State Coroner Iain West
    Anthony Joseph Mansbridge COR 2011 0156 Finding into death with inquest 06/06/2012 Deputy State Coroner Iain West
    Dane Alexander Hortle COR 2012 0380 Finding into death without inquest 10/12/2015 Deputy State Coroner Iain West
    Constantinos Retsas COR 2010 2063 Finding into death with inquest 21/02/2011 Deputy State Coroner Iain West
    Peter Kosciuk COR 2008 2860 Finding into death with inquest 13/02/2013 Deputy State Coroner Iain West
    Nuray Yurekturk COR 2010 4139 Finding into death with inquest 13/07/2011 Deputy State Coroner Iain West
    Robert Charles Avery COR 2010 4389 Finding into death with inquest 01/07/2015 Deputy State Coroner Iain West
    David Yannick Hollingsworth COR 2012 5287 Finding into death without inquest 19/12/2013 Deputy State Coroner Iain West
    Julie Stephens COR 2008 5746 Finding into death without inquest 04/03/2010 Deputy State Coroner Iain West