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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
Daniel Bryan Harvey COR 2020 004348 Finding into death with inquest 30/10/2025 Coroner Leveasque Peterson
Andrew Ewen Mallett COR 2024 007152 Finding into death without inquest 30/10/2025 Coroner Dimitra Dubrow
Raymond James Trimby COR 2022 007253 Finding into death without inquest 28/10/2025 Coroner Dimitra Dubrow
Rachel Frances Piskun COR 2023 000222 Finding into death without inquest 28/10/2025 Coroner Audrey Jamieson
Jean Elizabeth Crocker COR 2022 006702 Finding into death without inquest 28/10/2025 Coroner Catherine Fitzgerald
Solomone Kitione Charlie Taufe'ulungaki COR 2020 003201 Finding into death without inquest 23/10/2025 Coroner Ingrid Giles
John Frank Stubbs COR 2023 006881 Finding into death without inquest 21/10/2025 Deputy State Coroner Paresa Spanos
Raymond Charles Levy COR 2023 005837 Finding into death without inquest 20/10/2025 Coroner Ingrid Giles
Gary William Bruce COR 2023 002978 Finding into death without inquest 16/10/2025 Coroner Catherine Fitzgerald
Ms YPM COR 2020 002609 Finding into death without inquest 16/10/2025 Coroner Ingrid Giles