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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
Frank Kastelic COR 2024 004867 Finding into death without inquest 08/01/2025 State Coroner Judge John Cain
Winfried Medenbach COR 2023 006711 Finding into death without inquest 08/01/2025 Coroner Ingrid Giles
Ivy McGowan COR 2024 004859 Finding into death without inquest 08/01/2025 State Coroner Judge John Cain
Timothy John Jeitz COR 2024 004816 Finding into death without inquest 07/01/2025 State Coroner Judge John Cain
F T COR 2023 002103 Finding into death without inquest 07/01/2025 Coroner Ingrid Giles
Leah Pollauszach COR 2024 004853 Finding into death without inquest 07/01/2025 State Coroner Judge John Cain
Debra Louise Goold COR 2024 004865 Finding into death without inquest 07/01/2025 State Coroner Judge John Cain
C M COR 2024 000437 Finding into death without inquest 06/01/2025 Coroner John Olle
C E COR 2024 004763 Finding into death without inquest 24/12/2024 State Coroner Judge John Cain
Kerryn Swift COR 2024 004807 Finding into death without inquest 23/12/2024 State Coroner Judge John Cain