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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
    Mrs K COR 2017 1889 Finding into death without inquest 11/11/2020 State Coroner Judge John Cain
    Mr BT COR 2018 4185 Finding into death without inquest 10/11/2020 Coroner Audrey Jamieson
    Jessica Morgana Wilby COR 2018 4528 Finding into death without inquest 06/11/2020 Coroner Ian Guy
    Robert Thomas Love COR 2015 0833 Finding into death with inquest 06/11/2020 Coroner Audrey Jamieson
    VA COR 2018 5479 Finding into death without inquest 06/11/2020 Coroner Simon McGregor
    Sylvia Valerie Woolford COR 2018 3360 Finding into death without inquest 05/11/2020 Coroner Audrey Jamieson
    Norman MacKenzie COR 2017 1812 Finding into death with inquest 30/10/2020 Coroner Darren Bracken
    Valerie Margaret Fraser COR 2017 6116 Finding into death without inquest 30/10/2020 Coroner Darren Bracken
    Bo Zhao COR 2019 1132 Finding into death with inquest 29/10/2020 Coroner Sarah Gebert
    Phillip Harry Parker COR 2017 5085 Finding into death without inquest 22/10/2020 Coroner Audrey Jamieson