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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
Baby A COR 2020 007018 Finding into death with inquest 28/02/2023 Coroner Catherine Fitzgerald
Y GE COR 2019 007105 Finding into death without inquest 27/02/2023 Coroner Katherine Lorenz
Antony John Howard COR 2022 003307 Finding into death without inquest 23/02/2023 Coroner Simon McGregor
Cody Morrella Watson COR 2019 005247 Finding into death without inquest 23/02/2023 Deputy State Coroner Paresa Spanos
Terence Michael Brooks COR 2019 003571 Finding into death without inquest 23/02/2023 Coroner Simon McGregor
Do Hung Vu COR 2022 001234 Finding into death without inquest 21/02/2023 Deputy State Coroner Paresa Spanos
H YR COR 2018 004889 Finding into death without inquest 16/02/2023 Coroner Katherine Lorenz
Hassan Jeng COR 2018 000014 Finding into death with inquest 14/02/2023 State Coroner Judge John Cain
Andrew James McNeil COR 2019 004204 Finding into death without inquest 10/02/2023 Coroner Kate Despot
J R COR 2020 000390 Finding into death without inquest 09/02/2023 Deputy State Coroner Paresa Spanos