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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
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