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 |
---|---|---|---|---|---|---|
Maria James | COR 1980 1820 | Finding into death with inquest | 31/03/2022 | Deputy State Coroner Caitlin English | ||
Mladen Jovanoski | COR 2018 001694 | Finding into death with inquest | 11/07/2022 | Coroner David Ryan | ||
William Grant Keays | COR 2003 3683 | Finding into death with inquest | 15/08/2008 | Coroner Audrey Jamieson | ||
Ms Jane | COR 2017 002935 | Finding into death with inquest | 13/07/2022 | Deputy State Coroner Paresa Spanos | ||
Kai Wesley Wu | COR 2018 000675 | Finding into death with inquest | 21/12/2022 | Deputy State Coroner Paresa Spanos | ||
Shane Ronald Dennis Brown | COR 2021 002011 | Finding into death with inquest | 30/05/2023 | Coroner Leveasque Peterson | ||
Elly Rose Warren | COR 2016 005474 | Finding into death with inquest | 15/12/2023 | State Coroner Judge John Cain | ||
Jock Allan Adams | COR 2008 0087 | Finding into death with inquest | 05/03/2010 | Coroner Audrey Jamieson | ||
Dale Graham Russ | COR 2008 0142 | Finding into death with inquest | 10/06/2010 | Deputy State Coroner Paresa Spanos | ||
Mark Andrew Downie | COR 2007 0197 | Finding into death with inquest | 25/05/2010 | Coroner E. C. Batt |