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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
    Mark Edward Elliott COR 2020 000820 Finding into death without inquest 23/02/2022 Deputy State Coroner Caitlin English
    Matthew Lee Dongelmans COR 2020 001763 Finding into death with inquest 22/02/2022 Coroner David Ryan
    Roger David Batchelor COR 2021 001079 Finding into death with inquest 18/02/2022 Coroner Simon McGregor
    Elaine Betty Sime COR 2020 001836 Finding into death without inquest 17/02/2022 Coroner Audrey Jamieson
    Melissa Cunningham COR 2019 002936 Finding into death without inquest 14/02/2022 Coroner Leveasque Peterson
    John Francis Flynn COR 2019 007042 Finding into death without inquest 10/02/2022 Coroner Katherine Lorenz
    Linda-Jane Margaret Tatterson COR 2017 005904 Finding into death without inquest 09/02/2022 Deputy State Coroner Paresa Spanos
    Maxine Joyce Manwaring COR 2020 006348 Finding into death without inquest 09/02/2022 Coroner Sarah Gebert
    Travis Thomas Young COR 2019 005315 Finding into death with inquest 07/02/2022 Coroner Katherine Lorenz
    Iris Winifred Beecham COR 2019 002932 Finding into death without inquest 04/02/2022 Deputy State Coroner Paresa Spanos