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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
    Resel Juerchott COR 2019 2709 Finding into death without inquest 26/03/2021 Deputy State Coroner Paresa Spanos
    Josephine Helen Clarke COR 2018 4595 Finding into death without inquest 25/03/2021 Deputy State Coroner Caitlin English
    Kim Melissa Hall COR 2015 6534 Finding into death with inquest 19/03/2021 Deputy State Coroner Caitlin English
    Jessinda Kiroyan COR 2019 2493 Finding into death without inquest 19/03/2021 Deputy State Coroner Caitlin English
    BT COR 2019 1966 Finding into death without inquest 19/03/2021 Deputy State Coroner Caitlin English
    Stanley Bruce Weaver COR 2019 4563 Finding into death without inquest 18/03/2021 Coroner Jacqui Hawkins
    Colleen Elizabeth Fermanian COR 2017 1400 Finding into death with inquest 17/03/2021 State Coroner Judge John Cain
    Sarah Louise Rose COR 2014 1941 Finding into death with inquest 15/03/2021 Deputy State Coroner Paresa Spanos
    Lina Huynh COR 2017 4564 Finding into death without inquest 15/03/2021 State Coroner Judge John Cain
    Casey Evan Cahill COR 2019 5525 Finding into death without inquest 10/03/2021 Deputy State Coroner Caitlin English