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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
Karla Lee Jordan COR 2019 004648 Finding into death without inquest 11/04/2025 Deputy State Coroner Paresa Spanos
Paul Arthur Phelps COR 2024 000173 Finding into death without inquest 10/04/2025 Coroner Paul Lawrie
Remy Da Silva COR 2023 001630 Finding into death without inquest 10/04/2025 Deputy State Coroner Paresa Spanos
Barbara Anne Deal COR 2022 003557 Finding into death without inquest 10/04/2025 Coroner Audrey Jamieson
Andrew Cameron McDougall COR 2023 006610 Finding into death without inquest 10/04/2025 Coroner Audrey Jamieson
COR 2019 006445 Finding into death with inquest 10/04/2025 Coroner Sarah Gebert
Child A . COR 2020 001984 Finding into death without inquest 09/04/2025 State Coroner Judge John Cain
Mark Andrew Harvey COR 2024 004847 Finding into death without inquest 08/04/2025 State Coroner Judge John Cain
Harold Lester Clayton COR 2023 005337 Finding into death without inquest 08/04/2025 State Coroner Judge John Cain
John Stuart Richards COR 2024 005418 Finding into death without inquest 07/04/2025 State Coroner Judge John Cain