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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
Mangalore Aircraft Accident . COR 2020 000950 Finding into death with inquest 14/08/2024 State Coroner Judge John Cain
Gayle Dianne Ireland COR 2024 000568 Finding into death without inquest 14/08/2024 State Coroner Judge John Cain
Brent Robert TRICKEY COR 2021 002091 Finding into death without inquest 14/08/2024 Coroner John Olle
Pramod Acharya COR 2023 002637 Finding into death without inquest 14/08/2024 Coroner Simon McGregor
Alan Edward Stewart COR 2018 004070 Finding into death with inquest 13/08/2024 Coroner Paul Lawrie
Danielle Cadan COR 2024 001869 Finding into death without inquest 12/08/2024 Coroner Katherine Lorenz
Angus Gordon Carruthers Collins COR 2023 000641 Finding into death without inquest 12/08/2024 Coroner David Ryan
Mr N COR 2022 005313 Finding into death without inquest 08/08/2024 Coroner Sarah Gebert
Jason . COR 2021 005548 Finding into death without inquest 07/08/2024 Coroner Sarah Gebert
Andrew David Berry COR 2020 000259 Finding into death with inquest 07/08/2024 Coroner Paul Lawrie