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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
L I COR 2019 000537 Finding into death with inquest 24/05/2024 Coroner Ingrid Giles
Jacob William Kennedy COR 2017 0595 Finding into death with inquest 24/05/2024 Coroner John Olle
Andrew Peter De Julia COR 2023 001795 Finding into death without inquest 21/05/2024 Coroner Catherine Fitzgerald
Denise Lucina Roberts COR 2023 002843 Finding into death without inquest 16/05/2024 Coroner David Ryan
Brian Richard Pope COR 2022 000975 Finding into death with inquest 16/05/2024 Coroner Simon McGregor
Robert Leonard Morris COR 2022 000536 Finding into death without inquest 16/05/2024 Coroner David Ryan
Mr A COR 2020 006382 Finding into death without inquest 16/05/2024 Coroner Audrey Jamieson
PJQ PJQ COR 2022 001089 Finding into death with inquest 14/05/2024 Coroner David Ryan
Victor Dale Fenech COR 2022 000655 Finding into death without inquest 13/05/2024 Coroner Katherine Lorenz
J V COR 2023 005572 Finding into death without inquest 13/05/2024 Coroner Sarah Gebert