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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 Sort ascending Date Coroner Related orders and rulings Responses to recommendations
    Taniela Ahokava COR 2016 004157 Finding into fire with inquest 20/03/2023 Deputy State Coroner Paresa Spanos
    Agostino Cutugno COR 2017 4222 Finding into death without inquest 30/08/2019 Coroner Simon McGregor
    Sophie Margery Nicholas COR 2016 4391 Finding into death without inquest 07/10/2019 Coroner John Olle
    FDS COR 2017 4687 Finding into death without inquest 16/10/2019 Deputy State Coroner Paresa Spanos
    Prisoner A COR 2018 4087 Finding into death without inquest 29/01/2020 Coroner John Olle
    Matthew John George COR 2014 5930 Finding into death without inquest 26/03/2020 Deputy State Coroner Paresa Spanos
    Robert James Lawerence COR 2016 4995 Finding into death without inquest 06/04/2020 Deputy State Coroner Paresa Spanos
    Jolanta Boyd COR 2018 2910 Finding into death without inquest 11/05/2020 Coroner Audrey Jamieson
    Stephen Myall COR 2018 1210 Finding into death without inquest 04/08/2020 Coroner Ian Guy
    Ms MH COR 2019 3839 Finding into death without inquest 07/09/2020 Coroner Audrey Jamieson