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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
R B COR 2019 001076 Finding into death without inquest 02/07/2024 Coroner Paul Lawrie
Joshua Steven Kerr COR 2022 004536 Finding into death with inquest 01/07/2024 Coroner David Ryan
Ms T COR 2023 001006 Finding into death without inquest 27/06/2024 Coroner Sarah Gebert
John Henry Hamilton COR 2023 004221 Finding into death without inquest 25/06/2024 Deputy State Coroner Paresa Spanos
Vincenzo Lobosco COR 2022 003460 Finding into death with inquest 24/06/2024 Coroner Ingrid Giles
X Y COR 2021 003810 Finding into death with inquest 19/06/2024 Coroner Simon McGregor
Joshua Paul Coates COR 2022 001708 Finding into death without inquest 17/06/2024 Coroner David Ryan

Dorevitch Pathology was required to respond by 17 September 2024. No response has been received to date.

Russell James Aldridge COR 2023 005470 Finding into death without inquest 14/06/2024 Coroner Catherine Fitzgerald
Jennifer Rowallan Turnbull COR 2022 006316 Finding into death without inquest 13/06/2024 Coroner David Ryan
Martin Page COR 2022 005163 Finding into death with inquest 12/06/2024 Coroner Catherine Fitzgerald