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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
Melanie Louise Gregory COR 2024 002112 Finding into death with inquest 10/07/2025 Coroner Dimitra Dubrow
Gregory Walter Heenan COR 2025 002041 Finding into death without inquest 09/07/2025 Coroner Leveasque Peterson
Geoffrey David Thorn COR 2023 004923 Finding into death without inquest 09/07/2025 Coroner John Olle
KD . COR 2022 005569 Finding into death without inquest 09/07/2025 Coroner Audrey Jamieson
Errol Leslie Solly COR 2021 003110 Finding into death without inquest 08/07/2025 Coroner Audrey Jamieson
Joan Pauline Skillen COR 2024 005786 Finding into death without inquest 07/07/2025 Coroner Dimitra Dubrow
Stephanie Rebernik COR 2023 001125 Finding into death without inquest 07/07/2025 Coroner Paul Lawrie
JV M COR 2022 002022 Finding into death without inquest 03/07/2025 Coroner John Olle
Ross Robert Richards COR 2023 002700 Finding into death without inquest 03/07/2025 Coroner Dimitra Dubrow
Caine David Knight COR 2023 005179 Finding into death without inquest 02/07/2025 Coroner David Ryan