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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 ascending Date Coroner Related orders and rulings Responses to recommendations
    Daniel Michael Miles COR 2015 0295 Finding into death without inquest 22/04/2016 Coroner Audrey Jamieson
    Oscar Nicholas McIntyre COR 2012 0741 Finding into death without inquest 14/04/2016 Coroner Rosemary Carlin
    Paschaliny Berias COR 2008 0782 Finding into death without inquest 21/04/2010 Coroner Audrey Jamieson
    Troy Daniel Saint COR 2013 0855 Finding into death without inquest 07/11/2016 Coroner Audrey Jamieson
    Jeffrey Coote COR 2017 1011 Finding into death without inquest 19/01/2018 Coroner Audrey Jamieson
    Chanel Peckham COR 2010 1291 Finding into death without inquest 06/09/2012 Coroner Audrey Jamieson
    Margaret Elizabeth Barton COR 2015 1527 Finding into death without inquest 30/11/2017 Deputy State Coroner Iain West
    Roderick Allen COR 2009 1608 Finding into death without inquest 23/08/2011 Coroner Kim M. W. Parkinson
    Warren Meyer COR 2011 1660 Finding into death without inquest 15/12/2017 Coroner John Olle
    Stanislaw Edward Czubryj COR 2017 1790 Finding into death without inquest 22/02/2018 Coroner Audrey Jamieson