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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 ascending Coroner Related orders and rulings Responses to recommendations
    Hannah Gray COR 2023 005071 Finding into death without inquest 17/09/2024 Deputy State Coroner Paresa Spanos
    Christos Pittas COR 2022 002855 Finding into death without inquest 16/09/2024 Coroner David Ryan
    Christine Anne Flanagan COR 2023 004146 Finding into death with inquest 12/09/2024 Coroner Leveasque Peterson
    Ms N COR 2023 005546 Finding into death without inquest 11/09/2024 Coroner Sarah Gebert
    Rosemarie Paton COR 2023 002611 Finding into death without inquest 06/09/2024 Coroner Paul Lawrie
    Russell Leslie James Hewat COR 2021 006058 Finding into death without inquest 06/09/2024 Coroner Audrey Jamieson
    Jing Hui Chen COR 2023 002230 Finding into death without inquest 04/09/2024 Coroner Simon McGregor
    Ryley Ann Cox COR 2023 005416 Finding into death without inquest 03/09/2024 Coroner Catherine Fitzgerald
    Matilda Ruby Armstrong COR 2022 003670 Finding into death without inquest 03/09/2024 Coroner Katherine Lorenz
    Laurence John Cox COR 2023 005415 Finding into death without inquest 03/09/2024 Coroner Catherine Fitzgerald