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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
    Stephen John Caruana COR 2017 5977 Finding into death without inquest 11/02/2019 Coroner Audrey Jamieson
    Phyllis Franke COR 2017 4540 Finding into death without inquest 08/02/2019 Coroner Phillip Byrne
    JP COR 2017 6372 Finding into death with inquest 07/02/2019 Coroner John Olle
    Eliza Gill COR 2016 4359 Finding into death without inquest 05/02/2019 Coroner Audrey Jamieson
    Pauline Mary Riordan COR 2013 5924 Finding into death with inquest 31/01/2019 Deputy State Coroner Paresa Spanos
    Bryan Lindsay Cleeman COR 2015 5014 Finding into death without inquest 24/01/2019 Deputy State Coroner Paresa Spanos
    Bella Jayde Lawrence COR 2015 4738 Finding into death without inquest 24/01/2019 Deputy State Coroner Iain West
    Stanley Hayhurst COR 2013 0294 Finding into fire with inquest 11/01/2019 Deputy State Coroner Iain West
    Zhikai Liu COR 2016 1035 Finding into death without inquest 10/01/2019 Coroner Audrey Jamieson
    Fiona Kellie Burke COR 2017 1253 Finding into death without inquest 08/01/2019 Coroner Audrey Jamieson