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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
    Taylor Zachary Oliver COR 2019 006595 Finding into death without inquest 15/12/2022 Coroner Katherine Lorenz
    Blake Edwards COR 2019 001722 Finding into death without inquest 13/12/2022 Coroner Kate Despot
    Scott Adam Brown COR 2019 004846 Finding into death with inquest 12/12/2022 Coroner Katherine Lorenz
    John Sloots COR 2022 000559 Finding into death without inquest 12/12/2022 Deputy State Coroner Paresa Spanos
    Ahmet Gezer COR 2019 006597 Finding into death with inquest 07/12/2022 State Coroner Judge John Cain
    D VR COR 2020 004470 Finding into death without inquest 06/12/2022 Coroner Simon McGregor
    Paul Kenneth Wright COR 2021 004932 Finding into death with inquest 06/12/2022 Coroner Simon McGregor
    Paul Desmond Smith COR 2018 005904 Finding into death without inquest 05/12/2022 Coroner Paul Lawrie
    Reece John Pullen COR 2021 005749 Finding into death with inquest 04/12/2022 Coroner David Ryan
    Alicia Maree Little COR 2017 006543 Finding into death with inquest 01/12/2022 State Coroner Judge John Cain