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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
Jacinta Pompei COR 2015 3627 Finding into death without inquest 09/04/2020 State Coroner Judge John Cain
Tanya Louise Day COR 2017 6424 Finding into death with inquest 09/04/2020 Deputy State Coroner Caitlin English
Kylie Maree Matchett COR 2019 2078 Finding into death without inquest 08/04/2020 Coroner Audrey Jamieson
Jesse Stephen Bird COR 2017 3044 Finding into death with inquest 07/04/2020 Coroner Jacqui Hawkins
Robert James Lawerence COR 2016 4995 Finding into death without inquest 06/04/2020 Deputy State Coroner Paresa Spanos
Darren Brandon COR 2018 2778 Finding into death with inquest 06/04/2020 Coroner Simon McGregor
Timothy Leighton Richardson COR 2019 3726 Finding into death without inquest 30/03/2020 Coroner John Olle
Richard Armstrong Lyon COR 2019 0638 Finding into death without inquest 27/03/2020 Coroner Simon McGregor
Matthew John George COR 2014 5930 Finding into death without inquest 26/03/2020 Deputy State Coroner Paresa Spanos
Eric Albert Ford COR 2018 5127 Finding into death without inquest 24/03/2020 Coroner Darren Bracken