Findings (2016/3)


This Practice Note applies to chambers findings and inquest findings ("findings") in relation to deaths reported on or after 22 July 2016. References to "the Act" are to the Coroners Act 2006. The Practice Note is to be read in conjunction with the Act. In the case of any inconsistency, the Act is to prevail.

Commencement of this Practice  Note

This Practice Note will apply from 22 July 2016 to all findings relating to deaths reported on or after 22 July 2016.


The Practice Note covers the following matters:

  • Findings’ precedents
  • Contents of findings
  • Notice of draft recommendations
  • Interested parties
  • Distribution
  • Specified recommendations or comments


This Practice Note is intended to improve the quality and consistency of findings.

Findings are sent to interested parties, including the family of the deceased. Findings are generally also available to researchers and the media (subject to sections 71 and 74 of the Act). In order to fulfil the purposes of the Act, which includes preventing the occurrence of deaths in circumstances similar to those in which the death being investigated occurred, it is important that all relevant information gathered during the inquiry and inquest is set out in the findings. This includes inquiries that return a negative result. For example, in the case of a self inflicted death, it can be important for researchers to know that the deceased was not enrolled with a GP. In the case of work place accidents it can be important to know that a toxicology test was done but nothing of note was detected.

Findings’ precedents

The findings’ templates are available in the Case Management System ("CMS") and in the Judicial Decision Interface. These templates will be used for all findings.

Contents of findings

[1] Findings will contain the followingelements:

  • (a)an introductory statement to orient the reader to the case; and
  • a statement of the issues to be decided; and
  • a description of the material facts relied on; and
  • a discussion of the facts as they relate to the resolution of the issues; and
  • the findings; and
  • any necessary orders (such as non-publication orders).

[2] Documents, witness statements or reports received by the coroner should not be listed but the facts outlined in the findings must be sufficient to explain the findings and the evidence relied on. If there are conflicts in the evidence before the coroner, and the evidence in conflict is relevant to the findings, the coroner must explain why the evidence relied on is preferred.

[3] For inquiries involving suspected self inflicted deaths, coroners must state whether they have found the death amounts to suicide or not. For those findings where suicide is found, the word “suicide” will appear on the certificate of findings1 and in the findings section of the written reasons for findings.

Notice of draft recommendations

[4] Where the coroner intends to make a recommendation or comment, the coroner will send a draft of the recommendation or comment to:

  • any expert from whom the coroner has received evidence under section 76, and
  • any other expert the coroner considers has an interest in the inquiry, and
  • any persons or organisations to whom the recommendation or comment is directed.

[5] The coroner will give those persons or organisations 20 working days to comment on the proposed recommendation or comment. The coroner will consider any response received in the timeframe provided before making the recommendation final.

[6] If the coroner receives a response to the draft recommendation before the findings are finalised, the coroner will make reference to the response in the findings.

Notice of adverse comments

[7] Where a coroner indicates an intention to make adverse comments under section 58 of the Act, the coroner may send only those sections of the draft findings to the recipients which are necessary to give that person a reasonable opportunity to be heard in relation to the proposed comment.

Interested parties

[8] The coroner will identify interested parties as required by the Act and will complete the initial review file note template to ensure that a complete list of interested parties is available to the case manager and in CMS. The coroner may need to review the list as the inquiry progresses and other parties become involved.


[9] If the coroner considers any person or organisation would benefit from receiving a copy of the findings, the coroner will specify the person or organisation sufficiently to allow the findings to be distributed to a particular person or organisation (as opposed to a generic group).

Specified recommendations/comments

[10] Specified recommendations and comments made pursuant to section 4 of the Act will be identified as either recommendations or comments in the findings. If a coroner makes general remarks in the course of the findings which are not specified recommendations or comments as defined in section 9 of the Act, the coroner must make it clear that the remarks are not specified recommendations or comments.

Judge Deborah Marshall
Dated: 21 July 2016

1 For example "Morphine overdose in circumstances amounting to suicide" or "Morphine overdose (suicide)".

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