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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
Gabriel Messo COR 2020 003809 Finding into death with inquest 19/01/2023 State Coroner Judge John Cain
Danny Lee O'Brien COR 2016 005829 Finding into death without inquest 19/01/2023 State Coroner Judge John Cain
David Julien Laurie Shan Gardner COR 2021 001686 Finding into death with inquest 18/01/2023 Deputy State Coroner Paresa Spanos
Andrew John Martin COR 2022 001527 Finding into death without inquest 11/01/2023 Deputy State Coroner Paresa Spanos
Paige Dent COR 2018 005030 Finding into death with inquest 10/01/2023 Coroner Darren Bracken
John Hardy Stow COR 2022 001246 Finding into death without inquest 05/01/2023 Deputy State Coroner Paresa Spanos
Charles Frederick Norton COR 2020 001163 Finding into death without inquest 03/01/2023 Coroner Audrey Jamieson
Mr L COR 2020 002747 Finding into death without inquest 30/12/2022 Coroner Sarah Gebert
Wei Hu COR 2019 005029 Finding into death without inquest 28/12/2022 State Coroner Judge John Cain
Kira Shae James COR 2017 005602 Finding into death with inquest 22/12/2022 Coroner Leveasque Peterson