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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
COR 2022 003072 Finding into death without inquest 19/05/2023 Deputy State Coroner Jacqui Hawkins
P A COR 2021 004832 Finding into death without inquest 18/05/2023 Deputy State Coroner Paresa Spanos
Nickolaos Vlahos COR 2021 005736 Finding into death without inquest 16/05/2023 Coroner David Ryan
Ian Keith Beissel COR 2022 3072 Finding into death without inquest 16/05/2023 Deputy State Coroner Jacqui Hawkins
Mathew James Luttrell COR 2018 005721 Finding into death with inquest 16/05/2023 Coroner Audrey Jamieson
Jennifer Mary Thomas COR 2021 003381 Finding into death with inquest 15/05/2023 Coroner David Ryan
John Edward Hadland (Millar) COR 2021 004640 Finding into death with inquest 11/05/2023 Coroner Paul Lawrie
Craig Harvey COR 2019 002141 Finding into death with inquest 11/05/2023 Coroner Catherine Fitzgerald
Jonathan Travis Palmer COR 2018 000917 Finding into death without inquest 10/05/2023 Coroner Audrey Jamieson
Mr C COR 2022 000827 Finding into death without inquest 03/05/2023 Coroner Sarah Gebert