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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
Belinda Ann Jones COR 2023 003937 Finding into death without inquest 03/09/2026 State Coroner Judge Liberty Sanger
Mitchell Luke Callaghan COR 2014 001033 Finding into death with inquest 02/09/2026 Coroner Catherine Fitzgerald
Mitchell Dean Johns COR 2021 002790 Finding into death with inquest 31/08/2026 Coroner Ingrid Giles
AQ AQ COR 2024 006825 Finding into death without inquest 31/08/2026 Deputy State Coroner Paresa Spanos
Jack Andrew Peter Stewart COR 2026 001272 Finding into death without inquest 31/08/2026 Coroner David Ryan
Susanne Keating COR 2021 001639 Finding into death without inquest 28/08/2026 Coroner Leveasque Peterson
Kristian David Reinertsen COR 2021 006600 Finding into death without inquest 28/08/2026 Coroner Leveasque Peterson
Allan James Anton COR 2025 006853 Finding into death without inquest 28/08/2026 Deputy State Coroner Paresa Spanos
Ashley John Bryant COR 2025 001108 Finding into death without inquest 27/08/2026 Coroner Therese McCarthy
Garry William Ledger COR 2025 006747 Finding into death without inquest 27/08/2026 Coroner Ingrid Giles