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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
James Bernard Williamson COR 2020 003705 Finding into death with inquest 20/04/2023 State Coroner Judge John Cain
Abdullahi Osman Bashir COR 2017 002767 Finding into death with inquest 18/04/2023 State Coroner Judge John Cain
Geunhee Park COR 2019 002270 Finding into death without inquest 17/04/2023 Coroner Simon McGregor
Paul Mervyn Gendre COR 2015 003431 Finding into death without inquest 17/04/2023 Coroner Audrey Jamieson
Deborah Leona Smith COR 2022 004607 Finding into death with inquest 03/04/2023 Coroner Simon McGregor
S M COR 2017 003664 Finding into death without inquest 02/04/2023 Coroner Audrey Jamieson
Suong Van Nguyen COR 2020 004355 Finding into death without inquest 31/03/2023 Coroner Leveasque Peterson
Cameron Douglas Boyes COR 2019 001516 Finding into death with inquest 30/03/2023 Coroner Leveasque Peterson
Steven John Bamblett COR 2020 000266 Finding into death without inquest 30/03/2023 Deputy State Coroner Paresa Spanos
Anna Lawrence COR 2020 002323 Finding into death without inquest 30/03/2023 Coroner Audrey Jamieson