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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
    Steven James Lawrie COR 2021 000791 Finding into death without inquest 25/05/2022 Coroner Simon McGregor
    Margaret Anne Brown COR 2021 002877 Finding into death without inquest 25/05/2022 Coroner Simon McGregor
    Mr A COR 2017 4986 Finding into death without inquest 23/05/2022 Coroner John Olle
    Marcus Lloyd Adams COR 2019 005134 Finding into death without inquest 20/05/2022 State Coroner Judge John Cain
    Mr P COR 2020 005219 Finding into death without inquest 20/05/2022 Coroner Sarah Gebert
    Cameron Richard Plant COR 2020 1982 Finding into death with inquest 17/05/2022 State Coroner Judge John Cain
    Cameron Richard Plant COR 2020 001982 Finding into death with inquest 17/05/2022 State Coroner Judge John Cain
    Mr J COR 2020 000549 Finding into death without inquest 17/05/2022 Coroner Sarah Gebert
    Jeanette Anne Moss COR 2014 0273 Finding into death with inquest 17/05/2022 State Coroner Judge John Cain
    Katrina Jarm COR 2019 004606 Finding into death without inquest 15/05/2022 Deputy State Coroner Paresa Spanos