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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
Ryley Ann Cox COR 2023 005416 Finding into death without inquest 03/09/2024 Coroner Catherine Fitzgerald
Laurence John Cox COR 2023 005415 Finding into death without inquest 03/09/2024 Coroner Catherine Fitzgerald
Matilda Ruby Armstrong COR 2022 003670 Finding into death without inquest 03/09/2024 Coroner Katherine Lorenz
Betty Eileen Cliffe COR 2023 001991 Finding into death without inquest 30/08/2024 Coroner Simon McGregor
Natalie Wilson COR 2020 004857 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Bridget Flack COR 2020 006727 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Mount Disappointment Helicopter Accident COR 2022 001771 Finding into death without inquest 29/08/2024 Coroner David Ryan
Baby A COR 2022 000345 Finding into death without inquest 29/08/2024 State Coroner Judge John Cain
A S COR 2021 002415 Finding into death with inquest 29/08/2024 Coroner Ingrid Giles
Doina Maria Predescu COR 2022 005042 Finding into death without inquest 29/08/2024 Coroner John Olle