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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
Mr EBG COR 2021 003131 Finding into death without inquest 19/07/2022 Coroner Simon McGregor
Dennis Alfred Goudge COR 2021 004013 Finding into death without inquest 19/07/2022 Coroner Leveasque Peterson
Dane Warren Simpson COR 2019 003390 Finding into death without inquest 19/07/2022 Coroner Darren Bracken
Michelle Hughes COR 2017 000422 Finding into death with inquest 14/07/2022 Coroner Darren Bracken
Ms Jane COR 2017 002935 Finding into death with inquest 13/07/2022 Deputy State Coroner Paresa Spanos
Catherine Ann Collier COR 2018 003667 Finding into death without inquest 12/07/2022 Coroner Simon McGregor
K LW COR 2021 004389 Finding into death without inquest 12/07/2022 Coroner John Olle
Timothy Dale Fehring COR 2019 003388 Finding into death without inquest 12/07/2022 Coroner Simon McGregor
Terry John Chandler COR 2021 0372 Finding into death without inquest 12/07/2022 Coroner Audrey Jamieson
David Andrew Coulter COR 2021 0452 Finding into death without inquest 12/07/2022 Coroner Audrey Jamieson