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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
Christopher David French Hunter COR 2015 003028 Finding into death with inquest 04/10/2022 Deputy State Coroner Paresa Spanos
Travis Jack Blows COR 2018 001703 Finding into death without inquest 04/10/2022 Coroner John Olle
Tom Owen Row COR 2022 000939 Finding into death without inquest 03/10/2022 Coroner Simon McGregor
Neville Ernest Mills COR 2021 003764 Finding into death without inquest 03/10/2022 Coroner David Ryan
Gillian Patricia Johnston COR 2020 007044 Finding into death without inquest 30/09/2022 Coroner John Olle
Baby RMI COR 2019 006834 Finding into death without inquest 30/09/2022 Coroner Katherine Lorenz
Y OA COR 2022 000026 Finding into death without inquest 29/09/2022 Coroner Simon McGregor
Colleen Mary Chapman COR 2020 000308 Finding into death without inquest 28/09/2022 Coroner Paul Lawrie
Mrs A COR 2019 006390 Finding into death without inquest 26/09/2022 State Coroner Judge John Cain
Colin Snooks COR 2017 005508 Finding into death without inquest 21/09/2022 State Coroner Judge John Cain