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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
Stephen Feltscheer COR 2024 004286 Finding into death without inquest 18/08/2025 Coroner Dimitra Dubrow
Cain Brian Cameron COR 2023 005977 Finding into death with inquest 15/08/2025 Coroner Catherine Fitzgerald
SJ I COR 2025 002585 Finding into death without inquest 15/08/2025 Coroner Kate Despot
Lillian Rose Thomas COR 2021 006144 Finding into death without inquest 13/08/2025 Coroner Catherine Fitzgerald
MNU . COR 2021 005550 Finding into death without inquest 13/08/2025 Coroner Sarah Gebert
JBL . COR 2024 003360 Finding into death without inquest 11/08/2025 Coroner Sarah Gebert
Raymond John Blackney COR 2023 004986 Finding into death without inquest 11/08/2025 Coroner Ingrid Giles
HBG . COR 2022 006877 Finding into death without inquest 11/08/2025 State Coroner Judge John Cain
DCF . COR 2022 002405 Finding into death without inquest 11/08/2025 State Coroner Judge John Cain
Brian Matthew McDonald COR 2024 005002 Finding into death without inquest 08/08/2025 Coroner Simon McGregor