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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
Tutapakore Ngatokoa COR 2024 004813 Finding into death without inquest 28/10/2024 State Coroner Judge John Cain
Loreta Maria Del Rossi COR 2024 002832 Finding into death without inquest 28/10/2024 State Coroner Judge John Cain
Bekkie-Rae Curren COR 2019 006509 Finding into death without inquest 25/10/2024 State Coroner Judge John Cain
TCW . COR 2018 000175 Finding into death without inquest 25/10/2024 State Coroner Judge John Cain
E K COR 2019 002791 Finding into death without inquest 25/10/2024 Coroner Ingrid Giles
Thanh Nguyen COR 2024 002678 Finding into death with inquest 25/10/2024 Coroner Leveasque Peterson
Maria Presti COR 2023 004650 Finding into death without inquest 25/10/2024 Coroner Catherine Fitzgerald
Judith Ann Johns COR 2023 003591 Finding into death without inquest 24/10/2024 Coroner Simon McGregor
Deborah Christine Barker COR 2022 002586 Finding into death without inquest 22/10/2024 Coroner Audrey Jamieson
Barry Robert Johnson COR 2022 002933 Finding into death without inquest 22/10/2024 Coroner Audrey Jamieson