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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
Anthony Joseph Moore COR 2025 004868 Finding into death without inquest 17/03/2026 Coroner David Ryan
Michelle Anne Leiper COR 2025 001347 Finding into death without inquest 17/03/2026 Coroner Ingrid Giles
Kwok Wah Yau COR 2024 007370 Finding into death without inquest 16/03/2026 Coroner Simon McGregor
Mark Andrew Harvey COR 2024 004847 Finding into death without inquest 16/03/2026 State Coroner Judge John Cain
John O'Grady COR 2025 003044 Finding into death without inquest 16/03/2026 Coroner Simon McGregor
Peter Collin Wells COR 2020 001821 Finding into death without inquest 13/03/2026 Coroner Audrey Jamieson
Fan Yang COR 2023 007184 Finding into death without inquest 13/03/2026 Coroner Audrey Jamieson
Virginia Catherine Harris COR 2025 001522 Finding into death without inquest 13/03/2026 Coroner Audrey Jamieson
Wayne Ronald Watson COR 2023 007233 Finding into death without inquest 13/03/2026 Coroner Ingrid Giles
Lee Yu Wu COR 2023 007176 Finding into death without inquest 13/03/2026 Coroner Audrey Jamieson