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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
Noel Edwin Capes COR 2023 004850 Finding into death without inquest 21/11/2024 Coroner Simon McGregor
Lorraine Marie Breen COR 2023 004849 Finding into death without inquest 21/11/2024 Coroner Simon McGregor
Ho Hai Vu COR 2024 002392 Finding into death without inquest 21/11/2024 Coroner Kate Despot
Kerry Kathleen Capes COR 2023 004851 Finding into death without inquest 21/11/2024 Coroner Simon McGregor
Baby LT COR 2019 003733 Finding into death without inquest 21/11/2024 Coroner Ingrid Giles
Trevor Michael Breen COR 2023 004848 Finding into death without inquest 21/11/2024 Coroner Simon McGregor
Daniel Surtees COR 2020 000474 Finding into death without inquest 19/11/2024 State Coroner Judge John Cain
Noeline Michelle Dalzell COR 2020 000670 Finding into death with inquest 18/11/2024 State Coroner Judge John Cain
Dean Andrew Broughton COR 2023 006352 Finding into death without inquest 18/11/2024 Coroner Dimitra Dubrow
Jeffrey Leigh Campbell COR 2024 004858 Finding into death without inquest 18/11/2024 State Coroner Judge John Cain