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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
Ms KSI COR 2018 000588 Finding into death without inquest 05/02/2024 State Coroner Judge John Cain
Angelo Angelino COR 2021 004915 Finding into death without inquest 01/02/2024 Coroner Simon McGregor
RT W COR 2021 006801 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles
HM Q COR 2022 003101 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles
RW C COR 2020 000709 Finding into death without inquest 31/01/2024 Coroner Ingrid Giles
Phyllis Joan Porter COR 2021 006663 Finding into death without inquest 30/01/2024 Coroner Paul Lawrie
Baby T S COR 2022 005413 Finding into death without inquest 30/01/2024 Coroner Sarah Gebert
David Sean Takwalai COR 2022 003588 Finding into death without inquest 30/01/2024 Coroner Kate Despot
Lachlan John Howe COR 2018 002344 Finding into death without inquest 29/01/2024 State Coroner Judge John Cain
Melissa Jan Hadland COR 2022 006064 Finding into death without inquest 25/01/2024 Coroner Leveasque Peterson