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 |
---|---|---|---|---|---|---|
Kent Thomas | COR 2018 6168 | Finding into death without inquest | 30/04/2021 | Coroner Sarah Gebert | ||
Spiros Boursinos | COR 2018 5273 | Finding into death with inquest | 29/04/2021 | Coroner Jacqui Hawkins | ||
Gary Edward Holmes | COR 2019 1935 | Finding into death without inquest | 28/04/2021 | Deputy State Coroner Caitlin English | ||
Mohamed Omar | COR 2017 3010 | Finding into death with inquest | 28/04/2021 | Deputy State Coroner Paresa Spanos | ||
Barbara Dawson | COR 1980 3469 | Finding into death with inquest | 16/04/2021 | Coroner Audrey Jamieson | ||
Mark James O'Brien | COR 2019 3863 | Finding into death with inquest | 14/04/2021 | Coroner Audrey Jamieson | ||
JJ | COR 2018 4398 | Finding into death without inquest | 14/04/2021 | Coroner Simon McGregor | ||
Jason Leslie Smith | COR 2018 1026 | Finding into death without inquest | 13/04/2021 | State Coroner Judge John Cain | ||
Michael James Woodhouse | COR 2018 4277 | Finding into death without inquest | 12/04/2021 | Coroner Leveasque Peterson | ||
Ian Lindsay Gould | COR 2019 4763 | Finding into death without inquest | 08/04/2021 | Coroner Simon McGregor |