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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
    Gary Edward Holmes COR 2019 1935 Finding into death without inquest 28/04/2021 Deputy State Coroner Caitlin English
    Mohamed Omar COR 2017 3010 Finding into death with inquest 28/04/2021 Deputy State Coroner Paresa Spanos
    Barbara Dawson COR 1980 3469 Finding into death with inquest 16/04/2021 Coroner Audrey Jamieson
    Mark James O'Brien COR 2019 3863 Finding into death with inquest 14/04/2021 Coroner Audrey Jamieson
    JJ COR 2018 4398 Finding into death without inquest 14/04/2021 Coroner Simon McGregor
    Jason Leslie Smith COR 2018 1026 Finding into death without inquest 13/04/2021 State Coroner Judge John Cain
    Michael James Woodhouse COR 2018 4277 Finding into death without inquest 12/04/2021 Coroner Leveasque Peterson
    Ian Lindsay Gould COR 2019 4763 Finding into death without inquest 08/04/2021 Coroner Simon McGregor
    Pamela Robson Pattison COR 2020 1237 Finding into death without inquest 07/04/2021 Coroner Darren Bracken
    Jordan COR 2016 6116 Finding into death with inquest 31/03/2021 Deputy State Coroner Paresa Spanos