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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
    Catherine Ann Williamson COR 2017 004582 Finding into death with inquest 22/06/2023 Coroner Audrey Jamieson
    Cherie Virginia Pearl Guest COR 2018 004091 Finding into death with inquest 22/06/2023 Coroner Katherine Lorenz
    Veronika (Veronica) Anastasia Kouros COR 2018 001293 Finding into death with inquest 22/06/2023 Coroner Audrey Jamieson
    Mr C COR 2021 001680 Finding into death without inquest 19/06/2023 Coroner Sarah Gebert
    Ngoc Bao Vy Tran COR 2021 005189 Finding into death without inquest 19/06/2023 State Coroner Judge John Cain
    Peter Henry Scerri COR 2021 002905 Finding into death with inquest 15/06/2023 Coroner Catherine Fitzgerald
    Kaleb Baylis-Clarke COR 2016 000423 Finding into death without inquest 14/06/2023 State Coroner Judge John Cain
    Robert Arthur Selby Lowe COR 2021 005913 Finding into death without inquest 14/06/2023 Deputy State Coroner Paresa Spanos
    Dianne Linford COR 2018 003161 Finding into death with inquest 06/06/2023 Coroner John Olle
    Emma Gertrude Weidemann COR 2019 006767 Finding into death without inquest 06/06/2023 Deputy State Coroner Paresa Spanos