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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
Ms K COR 2021 006401 Finding into death without inquest 02/08/2023 Coroner Sarah Gebert
Michael Stankic COR 2018 003392 Finding into death with inquest 31/07/2023 Deputy State Coroner Paresa Spanos
Loris Lesley O'Meara COR 2019 006497 Finding into death without inquest 31/07/2023 Coroner Paul Lawrie

The Minister was invited to respond but was not required to provide a response to recommendations. No response has been provided to date.

Marcus William Caldwell COR 2018 000790 Finding into death with inquest 28/07/2023 Coroner Sarah Gebert
Kelvin Maurice Jeffery COR 2020 003507 Finding into death without inquest 27/07/2023 Coroner Audrey Jamieson
Mr A . COR 2018 001635 Finding into death without inquest 27/07/2023 State Coroner Judge John Cain
Rona Jean Mccully COR 2022 006230 Finding into death without inquest 26/07/2023 Deputy State Coroner Paresa Spanos
Yukako Fukuhara COR 2022 002657 Finding into death without inquest 21/07/2023 Deputy State Coroner Jacqui Hawkins
Daryl William Nioa COR 2019 006741 Finding into death without inquest 19/07/2023 Coroner Audrey Jamieson
Reginald Desmond Benham COR 2019 004552 Finding into death without inquest 19/07/2023 Coroner Audrey Jamieson