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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
S R COR 2022 006787 Finding into death without inquest 28/02/2025 Coroner Ingrid Giles
E H COR 2022 006269 Finding into death without inquest 28/02/2025 Coroner Audrey Jamieson
Veeda . COR 2022 006788 Finding into death without inquest 28/02/2025 Coroner Ingrid Giles
Jonathan Alan Uphill COR 2022 001193 Finding into death without inquest 28/02/2025 Coroner Audrey Jamieson
Martin Barlow COR 2022 004423 Finding into death without inquest 28/02/2025 Coroner Audrey Jamieson
M S COR 2023 000264 Finding into death without inquest 27/02/2025 Deputy State Coroner Paresa Spanos
Frank Cecil Baker COR 2023 002344 Finding into death without inquest 27/02/2025 Deputy State Coroner Paresa Spanos
Douglas George Coyle COR 2023 003250 Finding into death without inquest 25/02/2025 Coroner Audrey Jamieson
Mark Fava COR 2023 006212 Finding into death without inquest 24/02/2025 Coroner David Ryan
Mia Rose Iskander COR 2022 003313 Finding into death without inquest 20/02/2025 Coroner Simon McGregor