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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
Mary Veronica Morrow COR 2021 3682 Finding into death without inquest 10/10/2023 Coroner Leveasque Peterson
G A COR 2017 5934 Finding into death with inquest 06/10/2023 Deputy State Coroner Paresa Spanos
Ruby-Lee Gold COR 2021 005748 Finding into death with inquest 05/10/2023 Coroner David Ryan
Wendy Joy Morgan COR 2023 000682 Finding into death without inquest 04/10/2023 Coroner David Ryan
Catherine Mary Lyons COR 2022 007234 Finding into death without inquest 04/10/2023 Coroner Katherine Lorenz
Trevor James Bayldon COR 2022 007435 Finding into death without inquest 04/10/2023 Coroner Catherine Fitzgerald
Student XRG COR 2020 003788 Finding into death without inquest 03/10/2023 Coroner Simon McGregor
Student AHT COR 2020 001525 Finding into death without inquest 03/10/2023 Coroner Simon McGregor
Student HBI COR 2020 001263 Finding into death without inquest 03/10/2023 Coroner Simon McGregor
Student FSB COR 2020 001132 Finding into death without inquest 02/10/2023 Coroner Simon McGregor