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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 Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Nicholas Raymond Lobo COR 2008 4896 Finding into death with inquest 01/12/2009 Deputy State Coroner Iain West
    Kenneth James Stephens COR 2016 5017 Finding into death with inquest 23/02/2018 Coroner Peter White
    Kevin Gary Dow COR 2009 5105 Finding into death with inquest 27/07/2013 State Coroner Judge Ian L Gray
    Susanne Maree Deeker COR 2013 5194 Finding into death with inquest 17/07/2014 Coroner Audrey Jamieson
    Laurel Faith Howard COR 2008 5806 Finding into death with inquest 20/05/2010 Deputy State Coroner Paresa Spanos
    Jordan Marcus Farr Pang COR 2013 5898 Finding into death with inquest 17/02/2017 Coroner Audrey Jamieson
    Stephanie Louise Meredith COR 2007 2125 Finding into death with inquest 21/10/2013 Coroner Dr Jane Hendtlass
    Ena Edith Vickers COR 2012 3130 Finding into death with inquest 25/02/2016 Coroner Phillip Byrne
    Leslie Hawkins COR 2018 5253 Finding into death with inquest 21/08/2019 Coroner Caitlin English
    Barry Scott Collins COR 2020 0646 Finding into death with inquest 04/12/2020 Deputy State Coroner Paresa Spanos