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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
    Taniela Ahokava COR 2016 004157 Finding into fire with inquest 20/03/2023 Deputy State Coroner Paresa Spanos
    Khaled El Rafihi COR 2019 001302 Finding into death without inquest 20/03/2023 Coroner Audrey Jamieson
    Christine Ann Stephen COR 2017 005661 Finding into death without inquest 19/03/2023 Coroner Audrey Jamieson
    Reginald William Griggs COR 2021 001876 Finding into death without inquest 17/03/2023 Coroner Simon McGregor
    H B COR 2013 003373 Finding into death with inquest 14/03/2023 Deputy State Coroner Paresa Spanos
    Jacqueline Isabella Vodden COR 2017 004768 Finding into death with inquest 14/03/2023 Coroner Sarah Gebert
    Bria Kathleen Joyce COR 2022 001937 Finding into death without inquest 14/03/2023 Coroner John Olle
    Armin Andrew Schaefer COR 2019 004452 Finding into death without inquest 10/03/2023 Coroner Simon McGregor
    Jarrod Peter Fox COR 2020 004529 Finding into death without inquest 08/03/2023 Coroner Audrey Jamieson
    Antoinette O'Brien COR 2017 004055 Finding into death with inquest 07/03/2023 State Coroner Judge John Cain