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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
Ingeburg Hildegard Muller COR 2018 004310 Finding into death without inquest 06/12/2021 Coroner Audrey Jamieson
Eden Herbert-Allan COR 2018 003944 Finding into death without inquest 06/12/2021 Coroner Audrey Jamieson
MA COR 2020 006348 Finding into death without inquest 02/12/2021 Coroner Sarah Gebert
Eileen Violet Smith COR 2019 004989 Finding into death without inquest 30/11/2021 Coroner Leveasque Peterson
Felicity Ruth Loveday COR 2021 0282 Finding into death with inquest 29/11/2021 Coroner Audrey Jamieson
Adrian Christian Victor Meneveau COR 2021 0279 Finding into death with inquest 29/11/2021 Coroner Audrey Jamieson
Daniel Neil Thomas COR 2017 001402 Finding into death with inquest 25/11/2021 Coroner Katherine Lorenz
Mark Leslie Missen COR 2016 001154 Finding into death without inquest 24/11/2021 State Coroner Judge John Cain
Nicholas Lopes COR 2020 000831 Finding into death with inquest 24/11/2021 Coroner Katherine Lorenz
Mr W COR 2018 006154 Finding into death without inquest 24/11/2021 Coroner Sarah Gebert