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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
Allison Leah Randall COR 2020 002716 Finding into death with inquest 26/04/2024 Coroner Sarah Gebert

The Chief Psychiatrist was required to respond by 2 August 2024. No response has been received to date.

Carolyn Mary James COR 2022 001604 Finding into death with inquest 23/04/2024 State Coroner Judge John Cain
Michael Molony COR 2021 002006 Finding into death with inquest 23/04/2024 Deputy State Coroner Paresa Spanos
Caroline Anne Willis COR 2018 002451 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain
Evlyn Kay James COR 2022 001605 Finding into death with inquest 23/04/2024 State Coroner Judge John Cain
Timothy Michael Funder COR 2022 006220 Finding into death without inquest 23/04/2024 Coroner Paul Lawrie
Jasmine Sara Thomas COR 2022 001606 Finding into death without inquest 23/04/2024 State Coroner Judge John Cain
HM I COR 2019 000188 Finding into death without inquest 22/04/2024 Coroner Ingrid Giles

Royal Australian College of General Practitioners (RACGP) was required to respond by 22 July 2024. No response has been received to date.

Baby B COR 2020 006592 Finding into death without inquest 22/04/2024 Coroner Audrey Jamieson
Patrick Anthony Barry COR 2023 003324 Finding into death without inquest 19/04/2024 Deputy State Coroner Paresa Spanos