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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
Edward Michael Schutz COR 2022 001727 Finding into death without inquest 13/09/2023 Coroner David Ryan
Catherine Myee Drinkwater COR 2022 6129 Finding into death without inquest 12/09/2023 Coroner Leveasque Peterson
Catherine Myee Drinkwater COR 2022 006129 Finding into death without inquest 12/09/2023 Coroner Leveasque Peterson
Nicola Jane Stephens COR 2018 006287 Finding into death with inquest 12/09/2023 State Coroner Judge John Cain
Angelo Anthony Gioscio COR 2022 004453 Finding into death with inquest 08/09/2023 Deputy State Coroner Jacqui Hawkins
Dorothy June McIntosh COR 2022 006347 Finding into death without inquest 08/09/2023 Coroner David Ryan
Betty Torrance Sloan COR 2019 003774 Finding into death with inquest 07/09/2023 Coroner David Ryan
Paul Kingsbury COR 2016 4835 Finding into death with inquest 05/09/2023 Coroner Leveasque Peterson
Master H COR 2022 005428 Finding into death without inquest 04/09/2023 Coroner Sarah Gebert
Jorgen Bottern COR 2021 003738 Finding into death without inquest 01/09/2023 State Coroner Judge John Cain